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A 58-year-old male presented with two generalised tonic-clonic seizures with post-ictal paranoia. Three months prior, he described an episode of being ‘hyper’ - characterised by running up and down the stairs. Investigations demonstrated mild hippocampal asymmetry on MRI, and temporal slowing (L>R) on EEG. He was initially diagnosed with focal onset epilepsy and discharged on levetiracetam. Over the following four months he continued to have episodes of abnormal behaviour, although without further tonic-clonic seizures. On further questioning it became evident that similar episodes had been occurring for the previous 3 years. During these episodes, various behaviours were described; laughing, running around, jumping on beds, doing handstands, pulling faces, opening and closing curtains - all of which self-terminated after a few hours. Consciousness was never impaired. The episodes frequently occurred on waking, were associated with diaphoresis, and improved with sugary foods. Reviewing ambulance records to previous callouts, hypoglycaemia was noted on initial assessment (blood glucose 1.2 - 2.3 mmol/L). A 72 hour fast was subsequently arranged, demonstrating fasting hypoglyaemia and inappropriate endogenous insulin secretion. Pancreatic imaging confirmed the presence of an insulinoma. Following resection, the patient is now symptom-free and off all medication.alexander.wallace2@wales.nhs.uk