An unusual cause for weight loss and diabetes.

A 71-year-old man presented with a 2-month history of acute-onset, progressive pain in the right upper abdomen, associated with nausea. He had no other symptoms or prior co-morbidities and a random plasma glucose level checked 6 months earlier had been normal. On examination, he had tender hepatomegaly with a hard consistency and nodular surface that extended 4 cm below the costal margin. He was found to have random plasma glucose level of 47 mmol/L, and was started on insulin. However, he had no symptoms of hyperglycaemia (polyuria, polydipsia, or polyphagia). Despite treatment with 80 to 100 IU of premixed insulin, his plasma glucose remained uncontrolled. Serum amylase and lipase were normal. He underwent magnetic resonance imaging of his abdomen (Fig 1). His fasting plasma glucagon levels were 182 pmol/L (reference range, 22.7-65 pmol/L). He underwent an ultrasound-guided biopsy of the liver lesion which was reported as neuroendocrine neoplasm with a MIB (Mind Bomb Homolog–1) proliferation index of 10 to 15% (Fig 2). The patient was treated with chemotherapy (carboplatin and etoposide, 6 cycles) and has been on follow-up for a year with diabetes in remission, and is clinically well although he has persistent hepatic metastases (revealed by Tc99m-octreotide scintigraphy) [Fig 3]. He was subsequently commenced on treatment with longacting octreotide on a monthly basis.