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Endgames Case report

An elderly woman with recurrent episodes of confusion

BMJ 2010; 340 doi: (Published 19 May 2010) Cite this as: BMJ 2010;340:c1998
  1. Augustin Brooks, specialist registrar,
  2. Bijay Vaidya, consultant endocrinologist
  1. 1Department of Endocrinology, Royal Devon and Exeter Hospital, Exeter
  1. Correspondence to: B Vaidya bijay.vaidya{at}

    An 84 year old woman presented with intermittent episodes of confusion that had been occurring for over six years. Her sister, with whom she lived, reported that during the episodes, the patient became clammy, confused, and sometimes drowsy. Following one of the early episodes, the patient was investigated for a possible transient ischaemic attack; however, a duplex scan showed only mild carotid disease.

    The patient’s symptoms usually occurred at times when she had not eaten for several hours, but occasionally they appeared after a meal. Over the years, her sister had noted that the symptoms could be promptly relieved by giving the patient orange juice. The patient had also learnt to take regular snacks between meals to prevent the symptoms. Consequently, she had gained 9 kg in weight over the six year illness period.

    During a particularly severe episode, the patient could not be aroused by her sister and an ambulance was called. The paramedic noted a low capillary blood glucose level of 2.7 mmol/l, and treated her with an intramuscular injection of glucagon. She was fully conscious on arrival at the accident and emergency department. Her serum glucose concentration was 4.1 mmol/l. She had no personal or family history of diabetes mellitus, and was not taking oral hypoglycaemic agents or insulin.


    • 1) What is the likely diagnosis?

    • 2) How would you biochemically confirm your diagnosis?

    • 3) What investigation would you do next to localise the underlying pathology causing the condition?

    • 4) What treatment would you recommend?


    1) What is the likely diagnosis?

    Short answer

    The most likely diagnosis is a hypoglycaemic disorder, although further investigations are warranted to look for an insulinoma.

    Long answer

    An insulinoma should be suspected if spontaneous hypoglycaemia occurs in an otherwise healthy individual. Insulinomas are rare pancreatic islet cell tumours and have been estimated to have an annual incidence of 4 cases per million …

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