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Kingsley Okolie, Daniel Chen, Raf Ghabrial, and Robert Schmidli

, a possible case of Marine–Lenhart syndrome. Case presentation A 61-year-old male Caucasian presented in 2016, with an episode of near-syncope, and was found to have suppressed TSH, slightly high free T3 and high-normal free T4; further

Open access

Arshpreet Kaur and Stephen J Winters

. Case presentation A 60-year-old man with T2DM treated with insulin, glimepiride, metformin and canagliflozin, as well as primary hypothyroidism and hypertension, was admitted to the hospital with altered mental status after a syncopal episode. He had

Open access

Xin Chen, Dina Kamel, Braden Barnett, Evan Yung, Adrienne Quinn, and Caroline Nguyen

she developed symptoms of diaphoresis, dizziness, tremors and syncope after meals. Workup revealed concurrent elevated insulin of 35.5 μIU/mL (normal range ≤3 μU/mL) and C-peptide of 6.75 nmol/L (normal range ≤0.2 nmol/L) during a hypoglycemic episode

Open access

Chih-Ting Su and Yi-Chun Lin

about 40 units. He started to use insulin aspart plus insulin glargine since 4 years ago and latest hemoglobin A1c was 7.6%. Frequent hypoglycemia and syncope events were noted for 1 year. At first, hypoglycemic coma happened about twice annually, but

Open access

Benjamin G Challis, Chung Thong Lim, Alison Cluroe, Ewen Cameron, and Stephen O’Rahilly

stable capillary blood glucose measurements (6.0–11.0mmol/L) achieved with progressively less total daily insulin that was eventually weaned completely. Four months later, however, the patient re-presented with lethargy and pre-syncopal episodes

Open access

Mohammed Faraz Rafey, Arslan Butt, Barry Coffey, Lisa Reddington, Aiden Devitt, David Lappin, and Francis M Finucane

Irish female had generalised weakness, dyspnoea and pre-syncope 3 days after elective laparoscopic right partial nephrectomy for removal of a renal oncocytoma. She had a history of type 2 diabetes for 17 years which was poorly controlled with a HbA1c of

Open access

Lima Lawrence, Peng Zhang, Humberto Choi, Usman Ahmad, Valeria Arrossi, Andrei Purysko, and Vinni Makin

presentation A 54-year-old gentleman presented to the emergency department with new-onset oral thrush and right-sided facial swelling after dental work. He had extensive recent evaluation for various complaints including weight gain, near-syncopal episodes

Open access

Marta Guimarães, Pedro Rodrigues, Sofia S Pereira, Mário Nora, Gil Gonçalves, Nicolai Wewer Albrechtsen, Bolette Hartmann, Jens Juul Holst, and Mariana P Monteiro


Post-prandial hypoglycemia is frequently found after bariatric surgery. Although rare, pancreatic neuroendocrine tumors (pNET), which occasionally are mixed hormone secreting, can lead to atypical clinical manifestations, including reactive hypoglycemia. Two years after gastric bypass surgery for the treatment of severe obesity, a 54-year-old female with previous type 2 diabetes, developed post-prandial sweating, fainting and hypoglycemic episodes, which eventually led to the finding by ultrasound of a 1.8-cm solid mass in the pancreatic head. The 72-h fast test and the plasma chromogranin A levels were normal but octreotide scintigraphy showed a single focus of abnormal radiotracer uptake at the site of the nodule. There were no other clinical signs of hormone secreting pNET and gastrointestinal hormone measurements were not performed. The patient underwent surgical enucleation with complete remission of the hypoglycemic episodes. Histopathology revealed a well-differentiated neuroendocrine carcinoma with low-grade malignancy with positive chromogranin A and glucagon immunostaining. An extract of the resected tumor contained a high concentration of glucagon (26.707 pmol/g tissue), in addition to traces of GLP1 (471 pmol/g), insulin (139 pmol/g) and somatostatin (23 pmol/g). This is the first report of a GLP1 and glucagon co-secreting pNET presenting as hypoglycemia after gastric bypass surgery. Although pNET are rare, they should be considered in the differential diagnosis of the clinical approach to the post-bariatric surgery hypoglycemia patient.

Learning points

  • pNETs can be multihormonal-secreting, leading to atypical clinical manifestations.
  • Reactive hypoglycemic episodes are frequent after gastric bypass.
  • pNETs should be considered in the differential diagnosis of hypoglycemia after bariatric surgery.

Open access

Jai Madhok, Amy Kloosterboer, Chitra Venkatasubramanian, and Frederick G Mihm


We report the case of a 76-year-old male with a remote history of papillary thyroid cancer who developed severe paroxysmal headaches in the setting of episodic hypertension. Brain imaging revealed multiple lesions, initially of inconclusive etiology, but suspicious for metastatic foci. A search for the primary malignancy revealed an adrenal tumor, and biochemical testing confirmed the diagnosis of a norepinephrine-secreting pheochromocytoma. Serial imaging demonstrated multiple cerebral infarctions of varying ages, evidence of vessel narrowing and irregularities in the anterior and posterior circulations, and hypoperfusion in watershed areas. An exhaustive work-up for other etiologies of stroke including thromboembolic causes or vasculitis was unremarkable. There was resolution of symptoms, absence of new infarctions, and improvement in vessel caliber after adequate alpha-adrenergic receptor blockade for the management of pheochromocytoma. This clinicoradiologic constellation of findings suggested that the etiology of the multiple infarctions was reversible cerebral vasoconstriction syndrome (RCVS). Pheochromocytoma remains a poorly recognized cause of RCVS. Unexplained multifocal cerebral infarctions in the setting of severe hypertension should prompt the consideration of a vasoactive tumor as the driver of cerebrovascular dysfunction. A missed or delayed diagnosis has the potential for serious neurologic morbidity for an otherwise treatable condition.

Learning points:

  • The constellation of multifocal watershed cerebral infarctions of uncertain etiology in a patient with malignant hypertension should trigger the consideration of undiagnosed catecholamine secreting tumors, such as pheochromocytomas and paragangliomas.
  • Reversible cerebral vasoconstriction syndrome is a serious but reversible cerebrovascular manifestation of pheochromocytomas that may lead to strokes (ischemic and hemorrhagic), seizures, and cerebral edema.
  • Alpha-adrenergic receptor blockade can reverse cerebral vasoconstriction and prevent further cerebral ischemia and infarctions.
  • Early diagnosis of catecholamine secreting tumors has the potential for reducing neurologic morbidity and mortality in patients presenting with cerebrovascular complications.
Open access

Anthony Logaraj, Venessa H M Tsang, Shahrir Kabir, and Julian C Y Ip

episode (systolic blood pressure 60 mmHg), hypoglycaemia of 3.2 mmol/L and syncope, which initially responded to fluid resuscitation, but recurred two hours later. Haemoglobin dropped from 96 g/L to 89 g/L. An urgent CT scan to exclude post