• CVD chemotherapy
• SDHB-mutation
• case report
• hypoglycemia
• metastatic paraganglioma

• Humans
• Male
• Adult
• Paraganglioma/genetics
• Paraganglioma/drug therapy
• Paraganglioma/pathology
• Succinate Dehydrogenase/genetics
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Mutation
• Cyclophosphamide/therapeutic use
• Cyclophosphamide/administration & dosage
• Vincristine/therapeutic use
• Lung Neoplasms/drug therapy
• Lung Neoplasms/genetics
• Lung Neoplasms/pathology
• Lung Neoplasms/secondary
• Prognosis
• Dacarbazine

• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/diagnosis
• Carcinoma, Hepatocellular/pathology
• End Stage Liver Disease/complications
• Humans
• Hypercalcemia/complications
• Hypercholesterolemia/complications
• Hypoglycemia/etiology
• Liver Neoplasms/pathology
• Paraneoplastic Syndromes/diagnosis
• Paraneoplastic Syndromes/etiology
• Polycythemia/complications
• Prognosis
• Retrospective Studies
• Severity of Illness Index
• Thrombocytosis/complications
• alpha-Fetoproteins/analysis

• Somalia
• hepatocellular carcinoma
• hypercalcemia

• IGF-II
• hepatocellular carcinoma
• hypoglycemia
• lnevatinib
• non-islet cell tumor hypoglycemia

• Aged
• Carcinoma, Hepatocellular/drug therapy
• Diabetes Mellitus, Type 2/complications
• Diabetes Mellitus, Type 2/drug therapy
• Humans
• Hypoglycemia/chemically induced
• Insulin-Like Growth Factor II
• Liver Neoplasms/drug therapy
• Male
• Phenylurea Compounds
• Quinolines

To describe a rare case of pheochromocytoma presenting with hypoglycemia.

We describe a rare case of pheochromocytoma presenting with a hypoglycemic seizure. Our article includes our differentials, work up, and management.

Our patient had non–islet-cell tumor hypoglycemia that was non-insulin mediated, as noted by low insulin levels. His hypoglycemia was likely multifactorial and mediated by different mechanisms. We describe the rare case and review the causes of tumor-induced hypoglycemia.

Pheochromocytomas can rarely present with hypoglycemia and are associated with a poor prognosis.

• IGF-2, insulin-like growth factor 2
• TIH, tumor-induced hypoglycemia
• hypoglycemia
• pheochromocytoma
• tumor-induced hypoglycemia

Non-islet cell tumor hypoglycemia (NICTH) is a rare cause of persistent hypoglycemia seen in patients with hepatocellular carcinoma (HCC). It is likely to be underdiagnosed especially in the patients with poor hepatic function and malnutrition. Herein, we report a rare case of NICTH as the initial presentation of HCC in a patient with chronic hypoglycemia due to end-stage liver cirrhosis.

A 62-year-old male with chronic fasting hypoglycemia secondary to end-stage hepatitis C-related cirrhosis, presented with altered mental status and dizziness. He was found to have severe hypoglycemia refractory to glucose supplements. Imaging studies and biopsy discovered well differentiated HCC without metastasis. Further evaluation showed low insulin, C-peptide and beta-hydroxybutyrate along with a high insulin-like growth factor-2/insulin-like growth factor ratio, consistent with the diagnosis of NICTH. As patient was not a candidate for surgical resection or chemotherapy, he was started on prednisolone with some improvements in the glucose homeostasis, but soon decompensated after a superimposed hospital acquired pneumonia.

NICTH can occur as the sole initial presentation of HCC and is often difficult to correct without tumor removal. Clinicians should maintain high clinical suspicion for early recognition of paraneoplastic NICTH in patients at risk for HCC, even those with chronic fasting hypoglycemia in the setting of severe hepatic failure and malnutrition.

• Non-islet cell tumor hypoglycemia
• Hepatocellular carcinoma
• Liver cirrhosis
• Insulin-like growth factor-2
• Paraneoplastic syndrome
• Case report

Hepatocellular carcinoma (HCC) affects more than half a million people worldwide each year. Paraneoplastic syndromes associated with HCC include erythrocytosis, hypercalcemia, hypercholesterolemia, hypoglycemia and thrombocytosis. Thrombocytosis is a rare paraneoplastic syndrome in HCC mediated by thrombopoietin (TPO) production. We report a case of thrombocytosis as a paraneoplastic syndrome in a patient with HCC and hepatitis C cirrhosis. A 56-year-old patient was evaluated with abdominal distension and pain of 1-month duration. He had a history of hepatitis C infection with liver cirrhosis, CTP (Child-Turcotte-Pugh) class C, MELD (model for end-stage liver disease) score 22, methadone dependence, alcohol abuse and depression. His physical examination was remarkable for distended abdomen with shifting dullness, palpable hepatomegaly and scleral icterus. Routine laboratory tests showed a platelet count of 754 k/µL, white blood cell count 12.4 k/µL, serum sodium level 128 mEq/L, alanine aminotransferase 93 U/L, aspartate aminotransferase 871 U/L, total serum bilirubin 4.3 mg/dL, direct serum bilirubin 2.8mg/dL and albumin 2.6 g/dL. Computed tomography of the abdomen and pelvis revealed hepatomegaly with numerous hypodensities suspicious for HCC. Abdominal paracentesis was done, serum ascites albumin gradient (SAAG) was 2.4 g/dL consistent with portal hypertension, and spontaneous bacterial peritonitis was ruled out. Magnetic resonance imaging of the liver was consistent with infiltrating HCC, portal vein thrombosis and retroperitoneal lymphadenopathy. His alpha fetoprotein (AFP) level was 79,102 ng/mL and TPO level was 126 pg/mL. JAK2 mutation was negative and no other cause of reactive thrombocytosis could be identified. One year prior to this admission, the patient was noted to have a normal platelet count and AFP level. He was not considered a candidate for liver transplantation due to ongoing substance abuse, and expired 1 month later. Thrombocytosis is a rare paraneoplastic condition seen in HCC. It is presumed to be secondary to increased production of TPO by the tumor. We observed an elevated level of TPO in our patient. Thrombocytosis in HCC is associated with a high tumor burden, portal vein thrombosis (PVT), serum AFP levels and a poor prognosis. Thrombocytosis in a cirrhotic patient should alert the presence of HCC and is associated with poor outcomes.

• Hepatocellular carcinoma
• Paraneoplastic syndrome
• Thrombocytosis

• Carcinoma, Hepatocellular/blood
• Coma/blood
• Female
• Humans
• Hypoglycemia/blood
• Hypoglycemia/etiology
• Liver Neoplasms/blood
• Middle Aged

Hepatocellular carcinoma (HCC) is ranked as the 5^th common type of cancer worldwide and is considered as the 3^rd common reason for cancer-related deaths. HCC often occurs on top of a cirrhotic liver. The prognosis is determined by several factors; tumour extension, alpha-fetoprotein (AFP) concentration, histologic subtype of the tumour, degree of liver dysfunction, and the patient’s performance status. HCC prognosis is strongly correlated with diagnostic delay. To date, no ideal screening modality has been developed. Analysis of recent studies showed that AFP assessment lacks adequate sensitivity and specificity for effective surveillance and diagnosis. Many tumour markers have been tested in clinical trials without progressing to routine use in clinical practice. Thus, surveillance is still based on ultrasound (US) examination every 6 mo. Imaging studies for diagnosis of HCC can fall into one of two main categories: routine non-invasive studies such as US, computed tomography (CT), and magnetic resonance imaging, and more specialized invasive techniques including CT during hepatic arteriography and CT arterial portography in addition to the conventional hepatic angiography. This article provides an overview and spotlight on the different diagnostic modalities and treatment options of HCC.

• Diagnosis of hepatocellular carcinoma
• Surgical resection
• Hepatocellular carcinoma
• Liver transplantation
• Radiofrequency ablation
• Microwave ablation
• Percutaneous ethanol or acetic acid ablation
• Radio-embolisation
• Systemic chemotherapy
• Trans-arterial chemoembolisation

• AFP, alpha-fetoprotein
• ALT, alanine aminotransferase
• AST, aspartate aminotransferase
• CEA, carcinoembryonic antigen
• HCC, hepatocellular carcinoma
• HHM, hypercalcemia of malignancy
• PTH, parathyroid hormone
• PTHrP, parathyroid hormone related peptide
• bisphosphonate
• hepatocellular carcinoma
• humoral hypercalcemia of malignancy
• non-cirrhotic liver
• paraneoplastic syndrome

Patient: Male, 71

Final Diagnosis: SIADH

Symptoms: Cachexia • confusion

Medication: —

Clinical Procedure: Percutaneous liver biopsy

Specialty: Oncology

• Autoantibodies/immunology
• Bronchial Neoplasms/complications
• Bronchial Neoplasms/metabolism
• Carcinoid Tumor/complications
• Carcinoid Tumor/metabolism
• Gastrointestinal Neoplasms/complications
• Gastrointestinal Neoplasms/metabolism
• Gastrointestinal Stromal Tumors/complications
• Gastrointestinal Stromal Tumors/metabolism
• Glucagon-Like Peptide 1/metabolism
• Humans
• Hypoglycemia/diagnosis
• Hypoglycemia/etiology
• Hypoglycemia/therapy
• Insulin-Like Growth Factor I/metabolism
• Insulin-Like Growth Factor II/metabolism
• Insulinoma/complications
• Insulinoma/metabolism
• Neoplasms/complications
• Neoplasms/immunology
• Neoplasms/metabolism
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/metabolism
• Paraneoplastic Syndromes/diagnosis
• Paraneoplastic Syndromes/etiology
• Paraneoplastic Syndromes/therapy
• Receptor, Insulin/immunology
• Somatostatin/metabolism

Background. Paraneoplastic syndromes (PNS) such as hypercalcaemia, hypercholesterolaemia, and erythrocytosis have been described in hepatocellular carcinoma (HCC). Aims. (1) To examine the prevalence, clinical characteristics, and survival of PNS in HCC patients and (2) to evaluate the extent to which each individual PNS impacts on patient survival. Methods. We prospectively evaluated the prevalence, clinical characteristics, and survival of PNS among 457 consecutive HCC patients seen in our department over a 10-year period and compared them with HCC patients without PNS. Results. PNS were present in 127 patients (27.8%). The prevalence of paraneoplastic hypercholesterolemia, hypercalcemia, and erythrocytosis 24.5%, 5.3%, and 3.9%, respectively. Patients with PNS had significantly higher alpha-fetoprotein levels, more advanced TNM stage, and shorter survival. Among the individual PNS, hypercalcemia and hypercholesterolemia were associated with more advanced disease and reduced survival but not erythrocytosis. On multivariate analysis, the presence of PNS was not found to be an independent prognostic factor for reduced HCC survival. Conclusion. PNS are not uncommon in HCC and are associated with poor prognosis and reduced survival due to their association with increased tumor burden. However, they do not independently predict poor survival. Individual PNS impact differently on HCC outcome; paraneoplastic hypercalcemia in particular is associated with poor outcome.

• hypoglycemia
• hyperglycemia
• diabetes mellitus
• emergency medicine
• intensive care unit
• anti-diabetic agents
• insulin

• Diabetes Mellitus/drug therapy
• Humans
• Hypoglycemia/blood
• Hypoglycemia/chemically induced
• Hypoglycemia/complications
• Hypoglycemia/epidemiology
• Hypoglycemic Agents/adverse effects
• Hypoglycemic Agents/therapeutic use
• Insulin/adverse effects
• Insulin/therapeutic use