title: Metastatic malignant insulinoma in a patient with type 2 diabetes mellitus: case presentation and literature review.
abstract: OBJECTIVE
  To describe the occurrence of metastatic malignant insulinoma in a patient with preexisting type 2 diabetes mellitus.
  
  
  METHODS
  We present a detailed case report, with clinical, biochemical, and imaging findings, and summarize the data from 21 similar cases in the literature.
  
  
  RESULTS
  The occurrence of malignant insulinoma in a patient with preexisting diabetes is very rare and thus can be a diagnostic challenge. In our patient with type 2 diabetes, endogenous hyperinsulinism was confirmed by demonstrating elevated insulin and C-peptide levels during hypoglycemic episodes in the absence of sulfonylurea on a blood screen. Abdominal computed tomographic scan and magnetic resonance imaging revealed a pancreatic mass as well as metastatic lesions in the liver. The pancreatic mass was removed and confirmed to be a malignant insulinoma. This procedure was followed by disappearance of the hypoglycemic episodes as well as the diabetes for a few months. On follow-up, however, more metastatic lesions appeared in conjunction with a protracted course of hypoglycemia that necessitated treatment with antihypoglycemic agents and, 3 years after the initial surgical intervention, culminated in the death of the patient.
  
  
  CONCLUSIONS
  Our patient is one of the few subjects known to have a malignant insulinoma in conjunction with preexisting diabetes. A high degree of suspicion for the presence of an insulinoma should be maintained when unexplained hypoglycemic episodes occur in a patient with previously stable diabetes.
authors.affiliation: Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Elias S
authors.initials: ES
authors.lastname: Siraj
authors.forename: George
authors.initials: G
authors.lastname: Samuel
authors.forename: Suzan
authors.initials: S
authors.lastname: Saber
authors.forename: Samuel
authors.initials: S
authors.lastname: Samuel
authors.forename: Amir H
authors.initials: AH
authors.lastname: Hamrahian
authors.forename: S Sethu K
authors.initials: SS
authors.lastname: Reddy
mesh_terms: D000328:Adult; D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology; D007340:Insulinoma / Q000150:complications*; D008113:Liver Neoplasms / Q000556:secondary; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000150:complications*