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A rare case of psychosis

A rare case of psychosis. Dr. Sunil K Mathai Dr Charles Panackel Dept. of Gastroenterology MTH Kochi, Kerala Presenting Author – Dr Sunil K Mathai HOD Gastroenterology. History. 19 year male Student Change in behavior ~ 4 months. History. Running amok Intermittent panic attacks GTCS

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A rare case of psychosis

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  1. A rare case of psychosis Dr. Sunil K Mathai Dr Charles Panackel Dept. of Gastroenterology MTH Kochi, Kerala Presenting Author – Dr Sunil K Mathai HOD Gastroenterology

  2. History • 19 year male • Student • Change in behavior ~ 4 months

  3. History • Running amok • Intermittent panic attacks • GTCS • Seen by a neurologist – Evaluated with CT Brain and EEG and started on Valproate

  4. History • Continues to have abnormal behaviour • Death of father – recent ‘stressor’ • Morning symptoms (? School phobia) • Normal examination + CT brain • No significant organic findings ? Functional (Panic disorder) • Referred to a psychiatrist

  5. Psychiatrist consulted • Psychiatry evaluation and follow up

  6. At MTH • Continues to have symptoms and hence referred here. • Basic Hematological Investigations – normal • EEG, MRI brain– Normal

  7. At MTH • Has seizures in hospital • Treated with Eptoin • Blood results – RBS 40mg% • Prompt recovery with IV dextrose

  8. At MTH • Recurrent Hypoglycemia ??? • Cause for hypoglycemia ??? • Insulin secreting Tumors • Factitious • Mesenchymal tumors • Metabolic disorders

  9. At MTH • Sr. Insulin levels - 27.1 microIU/ml (Normal <5) • C –peptide level - 694pmol/L (Normal < 160) • Insulin/Sugar Ratio - 0.9 (Normal : 0.3-0.4) • Sr. Prolactin – normal • Sr. calcium – normal

  10. Low plasma glucose levels (less than 45 mg/dl) + • High serum insulin (>6 mU/ml) • Suggestive of hypoglycemia secondary to an insulinoma

  11. Provisional diagnosis – Insulinoma What next ? • Imaging study

  12. CT abdomen with contrast

  13. CT abdomen • Single well circumscribed lesion in neck of pancreas • Well enhancing in arterial phase • Suggestive of Neuroendocrine tumor (NET) of pancreas

  14. PD

  15. Endoscopic ultrasound EUS • Pancreas – 2 echogenic lesions • 1.8 X 2 cm sized, well defined lesion near neck region • 0.7 cm sized lesion just proximal to first

  16. Diagnosis • Symptomatic Hypoglycemia • Insulinoma Hyperinsulinemia

  17. Management Plan • Surgical removal – Enucleation • Smaller lesion close to MPD – post operatively chance of pancreatic fistula • ERCP + Elective PD stenting

  18. Surgery • Laparoscopic enucleation • Intra operative ultrasound

  19. Postoperative period • Uneventful • Rapid recovery • Post OP – RBS : normal

  20. insulinoma Normal pancreas

  21. Encapsulated well diffrentiated pancreatic neuroendocrine tumours

  22. Final diagnosis • Symptomatic hypoglycemia • Hypeinsulinemia • Encapsulated well differentiated pancreatic neuroendocrine tumors (NET) - insulinoma

  23. Insulinomas • Large majority present in 4th decade • Women > men (3:2) • Symptoms most common in early morning • Sporadic / associated with MEN 1

  24. Insulinomas - symptomatology • Whipple’s triad • Most patients have neuroglycopenic symptoms ~82 – 92% • apathy, amnesia, dizziness, confusion, and coma • Sympathetic overactivity • Often misdiagnosed as ‘ Neurological / psychiatric illness’

  25. Treatment of insulinoma • Medical therapy • Complex carbohydrates • Diazoxide (150-200 mg/day) • Octreotide / Lanreotide • Surgical therapy • Surgical exploration ( if no liver mets) – upto 80% curative

  26. Take home message • ‘Tubular vision’ in era of specialization • Go back to ‘basics’ • Newer modalities available for treatment of insulinomas • EUS & Intraoperative ultrasound are an essential tool

  27. Thank you… Special thanks to • Dept. of surgical Gastroenterology • Dept. of Endocrinology

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