International Journal of Medical and Pharmaceutical Case Reports

Extreme hypoglycemia in cases with insulinoma may be clinically manifested with epileptic reactions, most frequently described in literature as generalized tonic-clonic seizures.

We present a case of a 30-year old man who was hospitalized at the Clinic of Neurology of the University hospital “St. George” in Plovdiv, Bulgaria, because of frequent seizures (2-3/ week), manifested with impaired awareness, aggressiveness, agitation, and confusion, mainly in the morning. The patient had been initially treated in a psychiatric clinic, afterwards he was diagnosed with epilepsy and was treated with valproate without success. During his stay in the Clinic of Neurology the medical staff observed a couple of focal seizures with impaired awareness, turning head aside, fixed eyes, followed by aggressiveness, agitation, and postictal confusion.  Extremely low levels of blood sugar were measured in the morning – up to 1.3 mmol/l (referent limits 4.1-5.9 mmol/l). The polysomnography recording showed episodes of high voltage synchronous slow activity in all derivations at the time of the described above seizures and hypoglycemia, which were coped with 40% glucose solution. Insulinoma in contact with the tail of the pancreas was verified as a metabolically active lesion on PET/CT. The patient was directed to a surgical department for biopsy and treatment. Seizures stopped after surgical resection of insulinoma.

We consider the reported case is a diagnostic challenge because of the type of clinical manifestations and the absolute necessity of highly specialized imaging investigations for etiology precision.