Letter to the Editor
Dementia solved with surgery: Report of a case
Demencia curada con cirugía: a propósito de un caso
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The typical presentation of insulinoma is Whipple's triad: validated plasma blood sugar levels <50<span class="elsevierStyleHsp" style=""></span>mg/dl, symptoms consistent with hypoglycaemia and their resolution after glucose administration.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Upon revision of the medical literature available in PubMed using the key words “dementia”, “insulinoma” and “Alzheimer's disease”, we present the first case of cognitive impairment secondary to insulinoma in Europe and its resolution after surgical treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The subject is a 61 year-old female brought to the Emergency Department due to hypoglycaemia of 20<span class="elsevierStyleHsp" style=""></span>mg/dl with impairment of the consciousness level and recovery after intravenous infusion of glucose at 50%. Acute disease was ruled out at that moment and after blood sugar levels stabilisation. The Endocrinology department was informed. She had high blood pressure treated with enalapril 5<span class="elsevierStyleHsp" style=""></span>mg, incipient Alzheimer type dementia (GDS 4, CDR 1) treated with galantamine 24<span class="elsevierStyleHsp" style=""></span>mg and hysterectomy for uterine fibroids. During the 2 previous years, she had experienced feeling of objects spinning, general discomfort and pallor after walking 30<span class="elsevierStyleHsp" style=""></span>min. She was assessed by the Cardiology Department, where the presence of a heart condition was ruled out. 15 months before her admission, she was assessed by the Neurology department due to failure to perform instrumental activities. A complete examination was carried out and she was diagnosed with Alzheimer type dementia. Treatment was initiated with 5<span class="elsevierStyleHsp" style=""></span>mg of donepezil, but after 4 months, it was discontinued due to night terrors and episodes of visual hallucinations, and changed to galantamine 24<span class="elsevierStyleHsp" style=""></span>mg. She reported episodes consistent with hypoglycaemia, for which she had never been examined before, predominantly during the morning, which resolved with fruits or sweets. For the last 2 years approximately, the symptoms appeared when the subject was resting or performing activities that required effort. She had gained 12<span class="elsevierStyleHsp" style=""></span>kg of weight in that time. She denied taking unprescribed medication, having insulin or hypoglycaemic drugs available, consuming toxic agents, having dietary transgressions, fasting and doing exhausting exercise. The examination showed only class II obesity. A fasting test was performed, and the results were consistent with endogenous hyperinsulinism. Sulfonylurea detection was negative. Chromogranin A and neuron-specific enolase were normal. The abdominal CT scan and NMRI, the scintigram with somatostatin analogues and the PET–CT showed no evidence of injuries consistent with insulinoma. The pancreatic protocol CT scan in the ventral area of the body showed a hypervascularised image of 1.5<span class="elsevierStyleHsp" style=""></span>cm diameter and density alteration consistent with neuroendocrine tumour. The patient was assessed by hepato-biliary and pancreatic surgery, selecting elective surgery as the best option. The intraoperative ultrasound scan showed a hypoechoic image of 2<span class="elsevierStyleHsp" style=""></span>cm diameter, separated from the duct of Wirsung, in the pancreatic body. Tumour enucleation was performed. The intraoperative biopsy was consistent with insulinoma-like neuroendocrine tumour, confirmed in the definitive biopsy, with no data of malignancy in the piece. The study was completed to disregard diseases associated with the insulinoma, and it turned out to be negative.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient had a benign insulinoma that appeared initially as cognitive deterioration consistent with Alzheimer type dementia. Weight gain occurs in 18% of the patients.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Diagnosis delay is not unusual as the symptoms are frequently attributed to psychiatric, cardiac or neurological disease.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The biochemical diagnosis of the insulinoma is carried out with the fasting test.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Once it is done, the location diagnosis must be performed, as it is essential to differentiate between insulinoma and adult nesidioblastosis. It can be performed through non-invasive (ultrasound scan, CT scan, NMRI, PET–CT and scintigram) or invasive (endoscopic ultrasound scan,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> arteriogram and selective venous catheterization<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>) tests. Most of them are intrapancreatic, unique and smaller than 2<span class="elsevierStyleHsp" style=""></span>cm. The preferred treatment for this condition is surgery.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The selection of the procedure depends on the tumour mass, location, relation with neighbouring structures and pancreatic involvement.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In patients at high surgical risk, other less invasive treatments are preferred, such as drugs (analogues of somatostatin, diazoxide), ablative treatment of the injury with alcohol, radiofrequency ablation or embolization.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Regular reviews shall be carried out to rule out associated diseases or polyglandular syndrome. The patient was reassessed by the Neurology department 3 months after surgery and no data of cognitive impairment or failure were observed in the ordered tests. Nowadays, she's subject to regular reviews and she continues asymptomatic.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Tejera Pérez C, Flores García JÁ. Demencia curada con cirugía: a propósito de un caso. Med Clin (Barc). 2015;144:92–93.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Review of the clinical, histological, and molecular aspects of pancreatic endocrine neoplasms" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.A. Gumbs" 1 => "P.S. Moore" 2 => "M. Falconi" 3 => "C. Bassi" 4 => "S. Beghelli" 5 => "I. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2017 October | 4 | 2 | 6 |
| 2017 September | 10 | 5 | 15 |
| 2017 August | 6 | 3 | 9 |
| 2017 July | 11 | 3 | 14 |
| 2017 June | 10 | 4 | 14 |
| 2017 May | 6 | 2 | 8 |
| 2017 April | 7 | 2 | 9 |
| 2017 March | 4 | 4 | 8 |
| 2017 February | 6 | 1 | 7 |
