Indian Journal of PsychiatryIndian Journal of Psychiatry
Home | About us | Current Issue | Archives | Ahead of Print | Submission | Instructions | Subscribe | Advertise | Contact | Login 
    Users online: 1941 Small font sizeDefault font sizeIncrease font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References

 Article Access Statistics
    Viewed245    
    Printed0    
    Emailed0    
    PDF Downloaded62    
    Comments [Add]    

Recommend this journal

 


 
 Table of Contents    
LETTERS TO EDITOR  
Year : 2020  |  Volume : 62  |  Issue : 3  |  Page : 331-332
Rare tumor – insulinoma mimicking dissociative disorder


Department of Psychiatry, Netaji Subhash Chandra Bose Subharti Medical College, Meerut, Uttar Pradesh, India

Click here for correspondence address and email

Date of Submission05-Mar-2019
Date of Decision19-Jun-2019
Date of Acceptance08-Feb-2020
Date of Web Publication15-May-2020
 

How to cite this article:
Agarwal S, Saxena K, Dhami A. Rare tumor – insulinoma mimicking dissociative disorder. Indian J Psychiatry 2020;62:331-2

How to cite this URL:
Agarwal S, Saxena K, Dhami A. Rare tumor – insulinoma mimicking dissociative disorder. Indian J Psychiatry [serial online] 2020 [cited 2020 Jul 13];62:331-2. Available from: http://www.indianjpsychiatry.org/text.asp?2020/62/3/331/284445




Sir,

Insulinoma, a rare neuroendocrine tumor, presents with hypoglycemic symptoms, due to oversecretion of insulin. With the incidence of 1–4/1 million,[1] patients experience neuroglycopenic and adrenergic symptoms, relieved by the administration of carbohydrate. Symptoms are precipitated by fasting/exercise/stress.[2] Hypoglycemia due to any cause, including insulinoma, can present as dizziness and recurrent loss of consciousness, which can often be misdiagnosed as a dissociative disorder by any medical professional.[3] Delay in the diagnosis of insulinoma may occur as these symptoms are not unique to hypoglycemia or insulinoma and can further complicate the scenario.

A 20-year-old female with a history of episodic jerky movements with stiffness of body for 7 days was admitted, with glasgow coma scale (GCS) of E4V1M5 and right plantar Babinski positive. Six to eight episodes were reported, each lasting 15–20 s, associated with frothing and urinary incontinence, and precipitated by an emotional stressor. The patient developed confusion after the episode (lasting around ½ h) on the 2nd day of admission, with unconsciousness for 4 days.

Detailed history revealed multiple episodes of unconsciousness over the past 2 years, episodes lasting few minutes to hours but no specific frequency of occurrence and not associated with frothing, urinary/fecal incontinence, tongue bite, or confusional state. They were usually precipitated by a stressor. The case was initially diagnosed as dissociative convulsions (pseudoseizure) by the physician (1½ years back). Due to the absence of frothing/incontinence/tongue bite/altered sensorium and precipitation of symptoms due to stress, plausibly led the physician to come to a psychiatric diagnosis. She was then treated with antidepressants for few months by the physician. Furthermore, no neuroimaging/investigations were done to rule out seizures.

With no relief in the symptoms and a previous diagnosis of dissociative disorder, it led to the liaison with the psychiatrists on the day of current admission. A detailed history and mental status examination was done. No depressive or anxiety symptoms were found, and the patient was advised investigations due to atypical presentations now. Contrast-enhanced computed tomography of the abdomen revealed a well-defined soft-tissue lesion (41 mm × 32 mm) from the pancreatic tail. Magnetic resonance imaging of the brain showed a prominent pituitary gland (0.1 cm × 0.8 cm). Fasting serum insulin levels were elevated (46.10 muU/ml). Electroencephalogram revealed cerebral dysrhythmia. A diagnosis of seizure disorder secondary to insulinoma was made, and the patient was advised immediate surgery with appropriate pharmacological management. After the surgery, the patient regained consciousness with complete recovery. There were no reported seizure episodes or behavioral changes on 2-month follow-up.

Insulinoma, as rare as it is, was the underlying culprit in this case. A similar case has been reported by Jagadheesan and Suresh.[3] Rare physical illness such as insulinoma can mimic symptoms of dissociative disorder and often go undiagnosed. Episodes of hypoglycemia due to insulinoma can present as/mimic anxiety or conversion/dissociative symptoms.[4],[5] In our case, symptoms were precipitated by emotional stressors and thus misdiagnosed to be functional by health professionals. This led to a delay in the correct diagnosis. With this case report, we want to highlight the importance of investigations/neuroimaging in cases with differential diagnosis of dissociative/conversion disorders. Any symptom not proportionate to the stressor or recurrence of symptoms even with appropriate management should raise a suspicion to rule out organic causes. Since a psychiatrist may be the primary medical professionals attending to such cases, it is important that they also have the knowledge about this rare disorder and its presentations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Ito S, Ogawa Y, et al. Diagnosis and management of insulinoma. World J Gastroenterol 2013;19:829-37.  Back to cited text no. 1
    
2.
Shin JJ, Gorden P, Libutti SK. Pathophysiology, localisation and management. Future Oncol 2010;6:229-37.  Back to cited text no. 2
    
3.
Jagadheesan V, Suresh SS. Episodic confusional state: Due to insulinoma. Indian J Psychiatry 2008;50:197-9.  Back to cited text no. 3
    
4.
Alemdar M, Iseri P, Komsuoglu SS. Insulinoma in differential diagnosis of seizure disorder. J Neuropsychiatry Clin Neurosci 2006;18:247-8.  Back to cited text no. 4
    
5.
Mathur A, Gorden P, Libutti SK. Insulinoma. Surg Clin North Am 2009;89:1105-21.  Back to cited text no. 5
    

Top
Correspondence Address:
Kaveri Saxena
Department of Psychiatry, Netaji Subhash Chandra Bose Subharti Medical College, Meerut, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_129_19

Rights and Permissions




 

Top