Case presentation:
A 36 years old South Asian gentleman was brought by ambulance to the emergency department with an episode of generalized tonic-clonic seizures. At the time of the attack, the patient’s blood glucose checked via point of care testing was 1.6mmol. He was given IV dextrose., Physical examination after the patient regained consciousness revealed a temperature of 36.8 °C, respiratory rate 20/minute, blood pressure 135/80, heart rate 76/minute and oxygen saturation of 99% in room air. Cardiac, respiratory, abdominal and neurological examination was normal. Hypoglycemia workup revealed a normal cortisol level, elevated insulin and c-peptide level consistent with hyperinsulinemia. An MRCP,NM 18F-DOPA whole-body PET CT and Ga-68 DOTATATE scan were normal and did not reveal any pancreatic lesion consistent with insulinoma. Due to high suspicion of insulinoma and negative non-invasive imaging, an endoscopic ultrasound (EUS) was performed, which showed a hypoechoic homogenous mass lesion sized 13x9 mm in the proximal body/neck of the pancreas. A fine needle biopsy (FNA) via EUS was performed. Histopathology showed a well-differentiated neuroendocrine tumor, consistent with Grade 1 insulinoma (T1N0M0). The patient underwent a distal pancreatectomy and splenectomy.