Muhammad Iqbal.
An unusual cause of Fits.
Pak Armed Forces Med J Jan ;51(2):190-2.

A patient of 62 years age presented CMH Rawalpindi on with history of fits of 4 years duration and concurrent weight gain. She was a known hypertensive and taking combination n of calcium channel blockers, diuretic and Angiotensin converting enzyme inhibitor to control her blood pressure. She had been quite regular in taking her anti- hypertensive medication. She was also taking tab carbamazepine 100 mg tds to control her fits. Her clinical examination revealed an obese lady with blood pressure of 170/ 100. No neurological deficit was noted. Similarly rest of clinical examination was unrevealing. She had been thoroughly investigated for her fits and hypoglycemia. Her calcium level was within normal limits. CT scan brain and MRI brain were noted normal. She had been noted to have her blood sugar in lower limits and she was thought to have reactive huypoglycemia. Considering lower blood sugar levels she had been thought to have insulinoma but C.T Scan abdomen had yielded no clue about its presence. She underwent earlier coecliac axis angiography which was equally unrevealing. All these investigation had been carried out year earlier to her admission. Considering her normal investigations, hypoglycemia was thought to be no more than reactive and fits were considered to be due to epilepsy. During this year her fits had been rather frequent and hypoglycaemia gradually worsening. Her hypoglycaemia had become together some now that she had to be given daily glucose drips which compelled her for fresh admission and reinvestigations.

During her hospital stay she was reinvestigated for her hypoglycaemia. Her antihypertensive treatment was modified to verapamil as it prevents hypoglycaemia on its own merit apart from its being antihypertensive. Similarly her carbamazepine was chariged to phenytoin to exploit its anti-hypoglycemic action apart from its use to control her fits. She was placed on octeroid injections which effectively controlled her hypoglycaemia and obviated the need to use daily 10% dextrose. As this treatment was modified, she again under went C.T Scan abdomen and M.R.I abdomen which of course were noted normal. Celiac axis angiography with C.T Scan abdomen was done with no positive result. Blood sugar level and C-peptide levels were sent for interestingly with blood sugar of 2.2 mmol, normal C-peptide levels was noted dispelling possibility of insulinoma altogether. We made a thorough search for any exogenous insulin but could not get any clue. Having failed to solve the mystery, her blood sugar and C-peptide levels were again repeated which showed unequivocally raised levels of C-peptide levels in the setting of hypoglycemia leaving no doubt about insulinoma as cause of fits. As neither Endoscopic sonography nor intraoperative sonographic probe was available in Pakistan, so family of the patient decided to go to UK where she underwent partial pancreatectomy and splenectomy. Now the patient is asymptomatic and has no fits. She is taking no medicine except for her hypertension and has shed lot of weight.

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