Letter to the Editor
Refractory hypoglycemia as a presentation of lymphoma
Hipoglucemia refractaria como forma de presentación de linfoma
Antonio Rosales-Castillo
, Antonio Bustos-Merlo
Corresponding author
Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S2387020623005442" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.07.025" "estado" => "S300" "fechaPublicacion" => "2024-01-26" "aid" => "6407" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:87-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775323005213" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.07.030" "estado" => "S300" "fechaPublicacion" => "2024-01-26" "aid" => "6407" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:87-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Hipoglucemia refractaria como forma de presentación de linfoma" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "88" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Refractory hypoglycemia as a presentation of lymphoma" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Rosales-Castillo, Antonio Bustos-Merlo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Rosales-Castillo" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Bustos-Merlo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020623005442" "doi" => "10.1016/j.medcle.2023.07.025" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623005442?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323005213?idApp=UINPBA00004N" "url" => "/00257753/0000016200000002/v1_202401120527/S0025775323005213/v1_202401120527/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020623005478" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.08.004" "estado" => "S300" "fechaPublicacion" => "2024-01-26" "aid" => "6412" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:88-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Toxic epidermal necrolysis-like subacute cutaneous lupus erythematosus associated with breast cancer" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "88" "paginaFinal" => "89" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lupus cutáneo subagudo tipo necrólisis epidérmica tóxica asociado a cáncer de mama" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 605 "Ancho" => 755 "Tamanyo" => 98784 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous plaques with presence of blisters and areas of epithelial denudation with positive Nikolsky's sign on the upper back.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Francisco Orts Paco, Javier Ruiz Martínez, José Pablo Serrano Serra" "autores" => array:3 [ 0 => array:2 [ "nombre" => "José Francisco" "apellidos" => "Orts Paco" ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Ruiz Martínez" ] 2 => array:2 [ "nombre" => "José Pablo" "apellidos" => "Serrano Serra" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775323005250" "doi" => "10.1016/j.medcli.2023.08.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323005250?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623005478?idApp=UINPBA00004N" "url" => "/23870206/0000016200000002/v2_202401240540/S2387020623005478/v2_202401240540/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S238702062300548X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.07.026" "estado" => "S300" "fechaPublicacion" => "2024-01-26" "aid" => "6415" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:86-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Trichodysplasia spinuluosa secondary to glucocorticoids" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "86" "paginaFinal" => "87" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tricodisplasia espinulosa secundaria a glucocorticoides" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1010 "Ancho" => 1505 "Tamanyo" => 275455 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation, histopathology and response to treatment. A–C) Multiple keratotic follicular spines on erythematous papules in the malar and frontal regions suggestive of trichodysplasia spinulosa. D) Resolution after reducing the dose of prednisone and starting concomitant treatment with adapalene, with persistence of residual postinflammatory hyperpigmentation. E) Histopathology. Dilated follicles in the infundibulum with extensive hyperkeratosis (asterisk) and absence of hair bulbs (H-E 40×). F) Histopathology. Follicular inner sheath with abnormal maturation and trichohyalin eosinophilic granules with dyskeratosis (arrows) (H-E 200×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Álvaro Aguado Vázquez, Isabel Ruiz Carbonell, Almudena Mateu Puchades" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Álvaro" "apellidos" => "Aguado Vázquez" ] 1 => array:2 [ "nombre" => "Isabel" "apellidos" => "Ruiz Carbonell" ] 2 => array:2 [ "nombre" => "Almudena" "apellidos" => "Mateu Puchades" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775323005195" "doi" => "10.1016/j.medcli.2023.07.033" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323005195?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062300548X?idApp=UINPBA00004N" "url" => "/23870206/0000016200000002/v2_202401240540/S238702062300548X/v2_202401240540/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Refractory hypoglycemia as a presentation of lymphoma" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "88" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Antonio Rosales-Castillo, Antonio Bustos-Merlo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Antonio" "apellidos" => "Rosales-Castillo" "email" => array:1 [ 0 => "anrocas90@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Bustos-Merlo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipoglucemia refractaria como forma de presentación de linfoma" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypoglycaemia, defined by Whipple's triad, can be a medical emergency depending on its characteristics, and occurs most commonly in diabetic patients, predominantly in type 1 diabetes. Pharmacological causes (insulin, sulphonylureas…)<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> must always be ruled out initially and, depending on the patient’s condition, their association with serious emerging pathology, such as liver failure or sepsis. However, on certain occasions it may be the presenting symptom of a neoplasm unrelated to pancreatic islets, secondary to secretion of various factors.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a diffuse large B-cell lymphoma, which started with refractory hypoglycaemia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 62-year-old woman with a history of arterial hypertension and type 2 diabetes mellitus on treatment with metformin, presented with a 5 kg weight loss, asthenia and hyporexia, together with episodes of night sweats and dizziness with blood glucose levels of up to 55 mg/dL that had started a month and a half earlier. She associated intermittent epigastric discomfort together with abdominal distension and early satiety. Vital signs were normal, except for the increase in blood pressure (160/90 mmHg). Physical examination revealed a palpation of a hard, non-painful, hard mass in the umbilical region, with no palpation of peripheral lymph nodes. Initial laboratory tests showed elevated lactate dehydrogenase (LDH: 951 U/L; NV 10–247) and C-reactive protein (150.3 mg/L; NV 0.1–5); chest X-ray was normal, and the patient was admitted for further investigation. An abdominal ultrasound scan showed a 10 × 8 cm infiltrating retroperitoneal mass with irregular contours and no vascular invasion, which was confirmed by computed tomography. Laboratory tests showed very high levels of vitamin B12 (2000 pg/mL; VN 180–890). During admission, there was a tendency to hypoglycaemia both fasting and postprandial, with levels ranging from 55 mg/dL to 110 mg/dL, with episodes of sweating, tachycardia, pallor and associated dizziness, despite discontinuation of the oral antidiabetic drug at admission. A sample was taken for hormone determination and continuous perfusion with glucose saline (5%) was started. Despite this, episodes of hypoglycaemia persisted, so glucocorticoid treatment was started. Hormonal determinations showed normal thyroid and adrenal axis, together with insulin 3.9 μ IU/mL (NV 1.9–23), C-peptide 0.75 ng/mL (NV 0.8–4.2); IGF-I 58.6 ng/mL (NV 75–212), IGFBP3 1.61 μ g/mL (NV 3.4–7). IGF-II: 555 ng/mL (NV 396–1000). IGF-II/IGF-I ratio: 9.47. Negative anti-insulin antibodies. It was decided to approach the mass by ultrasound-guided core needle biopsy, the result being compatible with a centroblastic-type diffuse large B-cell lymphoma with germ cell phenotype.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient’s general condition improved with dexamethasone 4 mg/12 h, and glycaemia levels reached > 80 mg/dL. She was referred to haematology, where after 5 cycles of chemotherapy (EPOCH-R) there was complete remission of the disease and absence of new hypoglycaemia episodes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Within tumour-associated hypoglycaemias, three main groups can be distinguished: tumours of the pancreatic islets (insulin-producing); hypoglycaemias secondary to hepatic/adrenal infiltration/destruction; and hypoglycaemias induced by non-islet tumours. Within the latter group, the aetiopathogenesis is usually explained by the release of various factors that alter glucose metabolism: tumour necrosis factor-alpha, interleukin-6, catecholamines, IGF-I, IGF-II or precursors… Cases mediated by IGF-II or its precursors are sometimes encompassed under the term “non-islet cell tumour hypoglycaemia”. The proposed mechanisms are derived from increased tumour production of IGF-II forms (pro-IGF-II, big-IGF-II).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This is usually reflected in a hormonal profile with increased levels of pro-IGF-II or IGF-II, normal-low or decreased levels of IGFBP3, insulin/proinsulin and C-peptide. Another parameter usually determined is the IGF-II/IGF-I ratio, which in these cases is usually greater than 3:1 and more typically 10:1, as IGF-II levels are sometimes normal.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The tumours most commonly associated with this process are mesenchymal, epithelial, haematological<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> and neuroendocrine tumours.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Curative treatment is excision or tumour cure,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> which is often not possible; in addition, effective and rapid measures are required to control blood glucose levels, among which the following have been described: continuous glucose administration, somatostatin analogues, glucocorticoids, growth hormone and glucagon infusion.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">Informed consent was obtained for imaging and subsequent publication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">No funding was received.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">No conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of non-islet-cell tumor hypoglycemia: a clinical review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.W. Bodnar" 1 => "M.J. Acevedo" 2 => "M. Pietropaolo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1210/jc.2013-3382" "Revista" => array:6 [ "tituloSerie" => "J Clin Endocrinol Metab" "fecha" => "2014" "volumen" => "99" "paginaInicial" => "713" "paginaFinal" => "722" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24423303" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumor-induced hypoglycemia: an unusual case report and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Abdulhadi" 1 => "C. Anastasopoulou" 2 => "P. Lekprasert" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "AACE Clin Case Rep" "fecha" => "2020" "volumen" => "28" "paginaInicial" => "80" "paginaFinal" => "83" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-islet cell tumor hypoglycemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Scott" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpainsymman.2008.11.001" "Revista" => array:6 [ "tituloSerie" => "J Pain Symptom Manage" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "1" "paginaFinal" => "3" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19111777" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extreme hypoglycaemia in anaplastic large cell lymphoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Akavia" 1 => "I. Krause" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Eur J Case Rep Intern Med" "fecha" => "2017" "volumen" => "4" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rare presentation of hypoglycemia in a patient with anaplastic large-cell lymphoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Aldahash" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Case Rep Endocrinol" "fecha" => "2021" "volumen" => "2021" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000002/v2_202401240540/S2387020623005442/v2_202401240540/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000002/v2_202401240540/S2387020623005442/v2_202401240540/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623005442?idApp=UINPBA00004N" ]
