J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website https://www.jocmr.org

Case Report

Volume 12, Number 12, December 2020, pages 824-830

Severe Non-Islet Cell Hypoglycemia From Ileum-Origin Gastrointestinal Stromal Tumor Producing Insulin-Like Growth Factor-2 in a Patient With Liver Cirrhosis Due to Chronic Hepatitis B

Figure 1. Histological findings in surgically resected tissues (× 400). (a) Hematoxylin and eosin (H&E) staining: H&E staining shows irregular proliferation of oval, partially spindle cells. Immunohistochemical staining for c-kit (CD117) (b), vimentin (c), desmin (d), S-100 (e), smooth muscle actin (SMA) (f), CD34 (g): positive findings for c-kit and vimentin.

Figure 2. Enhanced abdominal computed tomography (CT). Non-enhanced multiple large and small tumors were found in the pelvic cavity on CT. Arrows show large tumors.

Figure 3. Histological findings in surgically resected tissues (× 200). (a) Hematoxylin-eosin (HE) staining. (b) Immunohistochemical staining with an anti-insulin-like growth factor-2 (IGF2) antibody (Anti-IGF2 antibody: ab9574, Abcam Ltd, Cambridge, UK). Cells were strongly stained with the anti-IGF2 antibody.

**Table 1.** Hematological and Blood Chemistry Tests (Mid-March, 2013 on Admission)
Tests	Results	Normal values
WBC: white blood cell count; RBC: red blood cell count; Hb: hemoglobin;, PLT: platelet; ret: reticulated PLT; TP: total protein; Alb: albumin; AST: aspartate transaminase; ALT: alanine transaminase; ALP: alkaline phosphatase; LDH: lactate dehydrogenase; GGT: gamma-glutamyl transpeptidase; T-Bil: total bilirubin; D-Bil: direct bilirubin; Cholin-E: cholinesterase; TC: total cholesterol; BUN: blood urea nitrogen; Cr: creatinine; UA: uric acid; CRP: C-reactive protein; Na: sodium; K: potassium; Cl: chlorine; PT: prothrombin time; PT-INR: PT-international normalized ratio; APTT: activated partial thromboplastin time; PCR-HBV: polymerase chain reaction-hepatitis B virus; HCVAb: hepatitis C virus antibody; RPR: rapid plasma regain; TPHA: Treponema pallidum hemagglutination test.
Hematological
WBC	9,700/µL	(3,300 - 8,600)
RBC	253 × 10⁴/µL	(435 - 555)
Hb	7.9 g/dL	(13.7 - 16.8)
Ht	24.8 %	(40.7 - 50)
PLT	12.7 × 10⁴/µL	(15.8 - 34.8)
ret	3.62 %	(5 - 15)
Urinalysis
Blood	(2+)
Protein	(3+)
Glucose	(-)
Sediment
RBC	26/µL	(0 - 20)
WBC	8/µL	(0)
Hyaline cast	1/µL
Squamous epithelium	6/µL
Blood chemistry
TP	5.8 g/dL	(6.6 - 8.1)
Alb	2.90 g/dL	(4.2 - 5.1)
AST	73 U/L	(13 - 70)
ALT	29 U/L	(10 - 42)
LDH	1,234 U/L	(124 - 222)
ALP	689 U/L	(106 - 322)
GGT	226 U/L	(13 - 64)
T-Bil	0.94 mg/dL	(0.4 - 1.5)
D-Bil	0.19 mg/dL	(0.1 - 0.3)
Cholin-E	221 U/L	(198 - 475)
TC	157 mg/dL	(142 - 248)
Amylase	209 U/L	(60 - 180)
Lipase	320 U/L	(6 - 212)
Ammonia	63 µmol/L	(10 - 36)
BUN	11 mg/dL	(8 - 20)
Cr	0.7 mg/dL	(0.65 - 1.07)
UA	5.2 mg/dL	(3.7 - 7.8)
CRP	0.15 mg/dL	(0.0 - 0.25)
Na	143 mEq/L	(138 - 145)
K	2.9 mEq/L	(3.6 - 4.8)
Cl	107 mEq/L	(101 - 108)
Coagulating system
PT	12.3 s	(control 10.8 s)
PT	81.0 %	(70 - 120)
PT-INR	1.14	(0.9 - 1.1)
APTT	27.2 s	(control 30.4 s)
Infectious disease
HBsAg	> 400
PCR-HBV	(-)
HCVAb	(-)
Syphilis
RPR	(-)
TPHA	(-)

Table 1. Hematological and Blood Chemistry Tests (Mid-March, 2013 on Admission)

Tests

Results

Normal values

WBC: white blood cell count; RBC: red blood cell count; Hb: hemoglobin;, PLT: platelet; ret: reticulated PLT; TP: total protein; Alb: albumin; AST: aspartate transaminase; ALT: alanine transaminase; ALP: alkaline phosphatase; LDH: lactate dehydrogenase; GGT: gamma-glutamyl transpeptidase; T-Bil: total bilirubin; D-Bil: direct bilirubin; Cholin-E: cholinesterase; TC: total cholesterol; BUN: blood urea nitrogen; Cr: creatinine; UA: uric acid; CRP: C-reactive protein; Na: sodium; K: potassium; Cl: chlorine; PT: prothrombin time; PT-INR: PT-international normalized ratio; APTT: activated partial thromboplastin time; PCR-HBV: polymerase chain reaction-hepatitis B virus; HCVAb: hepatitis C virus antibody; RPR: rapid plasma regain; TPHA: Treponema pallidum hemagglutination test.

Hematological

WBC

9,700/µL

(3,300 - 8,600)

RBC

253 × 10⁴/µL

(435 - 555)

7.9 g/dL

(13.7 - 16.8)

24.8 %

(40.7 - 50)

PLT

12.7 × 10⁴/µL

(15.8 - 34.8)

ret

3.62 %

(5 - 15)

Urinalysis

Blood

(2+)

Protein

(3+)

Glucose

(-)

Sediment

RBC

26/µL

(0 - 20)

WBC

8/µL

(0)

Hyaline cast

1/µL

Squamous epithelium

6/µL

Blood chemistry

5.8 g/dL

(6.6 - 8.1)

Alb

2.90 g/dL

(4.2 - 5.1)

AST

73 U/L

(13 - 70)

ALT

29 U/L

(10 - 42)

LDH

1,234 U/L

(124 - 222)

ALP

689 U/L

(106 - 322)

GGT

226 U/L

(13 - 64)

T-Bil

0.94 mg/dL

(0.4 - 1.5)

D-Bil

0.19 mg/dL

(0.1 - 0.3)

Cholin-E

221 U/L

(198 - 475)

157 mg/dL

(142 - 248)

Amylase

209 U/L

(60 - 180)

Lipase

320 U/L

(6 - 212)

Ammonia

63 µmol/L

(10 - 36)

BUN

11 mg/dL

(8 - 20)

0.7 mg/dL

(0.65 - 1.07)

5.2 mg/dL

(3.7 - 7.8)

CRP

0.15 mg/dL

(0.0 - 0.25)

143 mEq/L

(138 - 145)

2.9 mEq/L

(3.6 - 4.8)

107 mEq/L

(101 - 108)

Coagulating system

12.3 s

(control 10.8 s)

81.0 %

(70 - 120)

PT-INR

1.14

(0.9 - 1.1)

APTT

27.2 s

(control 30.4 s)

Infectious disease

HBsAg

> 400

PCR-HBV

(-)

HCVAb

(-)

Syphilis

RPR

(-)

TPHA

(-)

**Table 2.** Endocrinological and Diabetes-Related Tests (Mid-March, 2013 on Admission)
Tests	Results	Normal value
FT4: free T4; FT3: free T3; TSH: thyroid stimulating hormone; GH: growth hormone; PRL: prolactin; ACTH: adrenocorticotropic hormone; LH: luteinizing hormone; FSH: follicle stimulating hormone; IGF-1: insulin-like growth factor-1; HbA1c: hemoglobin A1c; GA: glycoalbumin.
FT4	1.14 ng/dL	0.97 - 1.80
FT3	3.36 pg/mL	2.73 - 4.50
TSH	8.76 µU/mL	0.3 - 3.0
GH	3.29 ng/mL (2.97 at other day)	< 2.47
PRL	26.3 ng/mL	4.9 - 20.3
ACTH	51.8 pg/mL	7 - 63
LH	16.8 mIU/mL
FSH	48.1 mIU/mL
IGF-1	27 ng/mL	70 - 219 at 65 years age
Aldosterone	67 pg/mL	36 - 240
Cortisol	16.6 µg/dL	6 - 21
Adrenaline	0.82 ng/mL	< 0.1
Noradrenaline	1.1 ng/mL	0.1 - 0.45
Dopamine	< 0.02 ng/mL	< 0.02
Glucose	25 mg/dL	78 - 103
Insulin	0.3 µU/mL	5 - 20
C-peptide	< 0.03 ng/mL	1 - 2
HbA1c (NGSP)	5.3%	4.1 - 5.9
GA %	15.7%	11.6 - 16
Anti-insulin antibody	< 0.4 U/mL
Glucagon loading test
Serum C-peptide
0 min	< 0.03 ng/mL
6 min	< 0.03 ng/mL

Table 2. Endocrinological and Diabetes-Related Tests (Mid-March, 2013 on Admission)

Tests

Results

Normal value

FT4: free T4; FT3: free T3; TSH: thyroid stimulating hormone; GH: growth hormone; PRL: prolactin; ACTH: adrenocorticotropic hormone; LH: luteinizing hormone; FSH: follicle stimulating hormone; IGF-1: insulin-like growth factor-1; HbA1c: hemoglobin A1c; GA: glycoalbumin.

FT4

1.14 ng/dL

0.97 - 1.80

FT3

3.36 pg/mL

2.73 - 4.50

TSH

8.76 µU/mL

0.3 - 3.0

3.29 ng/mL (2.97 at other day)

< 2.47

PRL

26.3 ng/mL

4.9 - 20.3

ACTH

51.8 pg/mL

7 - 63

16.8 mIU/mL

FSH

48.1 mIU/mL

IGF-1

27 ng/mL

70 - 219 at 65 years age

Aldosterone

67 pg/mL

36 - 240

Cortisol

16.6 µg/dL

6 - 21

Adrenaline

0.82 ng/mL

< 0.1

Noradrenaline

1.1 ng/mL

0.1 - 0.45

Dopamine

< 0.02 ng/mL

< 0.02

Glucose

25 mg/dL

78 - 103

Insulin

0.3 µU/mL

5 - 20

C-peptide

< 0.03 ng/mL

1 - 2

HbA1c (NGSP)

5.3%

4.1 - 5.9

GA %

15.7%

11.6 - 16

Anti-insulin antibody

< 0.4 U/mL

Glucagon loading test

Serum C-peptide

0 min

< 0.03 ng/mL

6 min

< 0.03 ng/mL