病例23-2018:一名有意识错乱和低血糖发作的36岁男性 - NEJM医学前沿
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病例23-2018:一名有意识错乱和低血糖发作的36岁男性
Case 23-2018 — A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia


Deborah J. Wexler ... 肿瘤 • 2018.07.26

病历陈述


Sarah J. Grzybinski女士(急诊医学):一名36岁男性因精神状态改变被收入本院。

患者健康状况一直良好,直至入院前6年,当时他的妻子观察到他有一次异常行为发作。在发作期间,发现患者在家中徘徊,不清楚自己在哪里。患者出现胡言乱语和无目的的手臂动作,并自述视物模糊。患者妻子注意到,患者似乎意识到自己在胡言乱语。患者在30分钟后恢复到正常基线精神状态。患者无法回忆起这次发作的细节,也未就医。

从入院前2年开始,患者每年有1或2次类似的发作。入院前4个月,发作变得更加频繁,每月发作1或2次。发作最常发生于患者饮酒后的夜晚。虽然患者将饮酒量从每次5~6份啤酒、每周数次减少至每次2~4份啤酒、每周数次,患者仍然会有间歇性的精神状态改变和胡言乱语。患者将这些发作归咎于压力,未就医。

入院前1日,患者与妻子外出进晚餐期间,患者妻子注意到,在得知他们的一个女儿在家中出现恶心、呕吐和发热之后,患者变得异常不安,好像“变了个人”。患者再次出现胡言乱语和无目的双手抽动。进餐后这些症状减少。症状消失后,患者曾提到白天几乎未进食。





作者信息

Deborah J. Wexler, M.D., Wendy Macias-Konstantopoulos, M.D., M.P.H., David G. Forcione, M.D., Lillian Xiong, M.D., Christy E. Cauley, M.D., and Kirsten J. Pierce, M.D.
From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School — both in Boston.

 

参考文献

1. Cryer PE, Axelrod L, Grossman AB, et al. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2009;94:709-728.

2. Case Records of the Massachusetts General Hospital (Case 33-2012). N Engl J Med 2013;368:487-487.

3. Siler SQ, Neese RA, Christiansen MP, Hellerstein MK. The inhibition of gluconeogenesis following alcohol in humans. Am J Physiol 1998;275:E897-E907.

4. Ismail AA. The insulin autoimmune syndrome (IAS) as a cause of hypoglycaemia: an update on the pathophysiology, biochemical investigations and diagnosis. Clin Chem Lab Med 2016;54:1715-1724.

5. Wong SL, Priestman A, Holmes DT. Recurrent hypoglycemia from insulin autoimmune syndrome. J Gen Intern Med 2014;29:250-254.

6. Abrahamsson N, Börjesson JL, Sundbom M, Wiklund U, Karlsson FA, Eriksson JW. Gastric bypass reduces symptoms and hormonal responses in hypoglycemia. Diabetes 2016;65:2667-2675.

7. Lee CJ, Wood GC, Lazo M, et al. Risk of post-gastric bypass surgery hypoglycemia in nondiabetic individuals: a single center experience. Obesity (Silver Spring) 2016;24:1342-1348.

8. Goldfine AB, Patti ME. New lessons from gastric bypass: impact of glucose-independent islet function. Obesity (Silver Spring) 2015;23:1942-1943.

9. Patti ME, Li P, Goldfine AB. Insulin response to oral stimuli and glucose effectiveness increased in neuroglycopenia following gastric bypass. Obesity (Silver Spring) 2015;23:798-807.

10. Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 2005;353:249-254.

11. Bernard B, Kline GA, Service FJ. Hypoglycaemia following upper gastrointestinal surgery: case report and review of the literature. BMC Gastroenterol 2010;10:77-77.

12. Lindeboom MY, Ringers J, van Rijn PJ, Neijenhuis P, Stokkel MP, Masclee AA. Gastric emptying and vagus nerve function after laparoscopic partial fundoplication. Ann Surg 2004;240:785-790.

13. Zaloga GP, Chernow B. Postprandial hypoglycemia after Nissen fundoplication for reflux esophagitis. Gastroenterology 1983;84:840-842.

14. Placzkowski KA, Vella A, Thompson GB, et al. Secular trends in the presentation and management of functioning insulinoma at the Mayo Clinic, 1987-2007. J Clin Endocrinol Metab 2009;94:1069-1073.

15. Service FJ. Diagnostic approach to adults with hypoglycemic disorders. Endocrinol Metab Clin North Am 1999;28:519-532, vi.

16. Heller SR, Cryer PE. Reduced neuroendocrine and symptomatic responses to subsequent hypoglycemia after 1 episode of hypoglycemia in nondiabetic humans. Diabetes 1991;40:223-226.

17. Ramanathan R, Cryer PE. Adrenergic mediation of hypoglycemia-associated autonomic failure. Diabetes 2011;60:602-606.

18. Allen KV, Pickering MJ, Zammitt NN, et al. Effects of acute hypoglycemia on working memory and language processing in adults with and without type 1 diabetes. Diabetes Care 2015;38:1108-1115.

19. Auer RN. Hypoglycemic brain damage. Metab Brain Dis 2004;19:169-175.

20. Suh SW, Hamby AM, Swanson RA. Hypoglycemia, brain energetics, and hypoglycemic neuronal death. Glia 2007;55:1280-1286.

21. Taboulet P, Deconinck N, Thurel A, et al. Correlation between urine ketones (acetoacetate) and capillary blood ketones (3-beta-hydroxybutyrate) in hyperglycaemic patients. Diabetes Metab 2007;33:135-139.

22. Hirshberg B, Livi A, Bartlett DL, et al. Forty-eight-hour fast: the diagnostic test for insulinoma. J Clin Endocrinol Metab 2000;85:3222-3226.

23. Service FJ, Natt N. The prolonged fast. J Clin Endocrinol Metab 2000;85:3973-3974.

24. Thompson SM, Vella A, Thompson GB, et al. Selective arterial calcium stimulation with hepatic venous sampling differentiates insulinoma from nesidioblastosis. J Clin Endocrinol Metab 2015;100:4189-4197.

25. Téllez-Ávila FI, Acosta-Villavicencio GY, Chan C, et al. Diagnostic yield of endoscopic ultrasound in patients with hypoglicemia and insulinoma suspected. Endosc Ultrasound 2015;4:52-55.

26. Basturk O, Farris AB III, Volkan Adsay N. Immunohistology of pancreas and hepatobiliary tract. In: Dabbs DJ, ed. Diagnostic immunohistochemistry: theranostic and genomic applications. 4th ed. Philadelphia: Elsevier Saunders, 2014:540-614.

27. Lewis RB, Lattin GE Jr, Paal E. Pancreatic endocrine tumors: radiologic-clinicopathologic correlation. Radiographics 2010;30:1445-1464.

28. Tamm EP, Bhosale P, Lee JH, Rohren EM. State-of-the-art imaging of pancreatic neuroendocrine tumors. Surg Oncol Clin N Am 2016;25:375-400.

29. Ashok AC, Harish K. Transduodenal enucleation of insulinoma in the head of the pancreas: a novel approach. J Surg Oncol 2008;97:173-175.

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