SUN-311 Pervasive Hypoglycemia in the Unconventional Face of Ovarian Cancer

Background:Hypoglycemia can quickly become a medical emergency. Causes of hypoglycemic episodes are most commonly iatrogenic specifically in diabetic patients but can also be accredited to endogenous causes relating to neoplastic growth; this includes tumor induced secretions and/or increased tumor glucose metabolism(1). Tumor-related hypoglycemia is classically thought to present as islet cell tumors of neuroendocrine origin known as insulinomas which result in excessive insulin secretion. Rarely, hypoglycemia can be in the setting of hypoinsulinemia and high IGF2/IGF1 suggesting non-islet cell tumors specifically of mesenchymal or epithelial origin with paraneoplastic secretion of IGF2(2). Case:A 74 year old female with history of hypothyroidism and uterine cancer presents to the emergency department (ED) with episodic hypoglycemia with a BG of 23 in the setting of frequent bouts of palpitations and sweating for the last week. Prior to arrival in the ED she summoned EMS to her home for an episode of shaking and pale appearance at which time EMS evaluated her, administered D50 and her hypoglycemia resolved. She had a repeat episode which prompted her arrival to the ED later that day. She had no known history of diabetes and was admitted for further evaluation. On exam, abdomen a palpable solid suprapubic mass was felt just above the umbilical region. Subsequent CT revealed a 25 cm intra-abdominal predominantly cystic and solid mass extending above the level of the umbilicus. Labs revealed elevated CA-125:344.8, CEA:97.17, IGF2:217, IGF1:18 (IGF2/IGF1 = 12.06) which raised suspicion for ovarian cancer and Gynecology-Oncology ultimately performed bilateral salpingo-oophorectomy. Histology results postoperatively revealed high grade serous adenocarcinoma in the left adnexa. Paraneoplastic IGF2 elevation secondary to her tumor was the likely culprit of substantially increased IGF2:IGF1 ratio (>10x) as well as the likely cause of her refractory hypoglycemia. After complete resection of the tumor, the hypoglycemic state dissipated. Discussion: This case illustrates one of the more novel causes of hypoglycemia. It is customary to recognize hypoglycemia in the realm of diabetic treatment or islet-cell tumors, but unusual causes such as any non-islet cell tumors including serous adenocarcinomas should also be considered. Dutta et al. discusses 5 cases of non-islet cell tumor induced hypoglycemia with hypoglycemic symptoms leading to the diagnosis of the tumor in 3 of the 5 cases and striking IGF2/IGF1 found in each case(3). Furthermore, with accumulating literature beginning to show a causal relationship between IGF2 inducing non-islet cell tumors and hypoglycemia, this case supports the notion of routine IGF2/IGF1 laboratory evaluation in patients presenting with spontaneous hypoglycemia with no readily discernable cause(5).