The After-Dinner Dip

This clinical case report describes an 85 year old woman of Eritrean descent who presented with recurrent postprandial hypoglycemia, weight loss, and episodes of syncope. Initial evaluation revealed Whipple’s triad (hypoglycemia, symptoms, and resolution with glucose administration), prompting investigation for hyperinsulinemic hypoglycemia. Despite elevated insulin and C peptide levels, imaging ruled out insulinoma. The diagnosis of insulin autoimmune syndrome (Hirata disease) was confirmed by the presence of high titer insulin autoantibodies. The patient was managed with a low carbohydrate diet, octreotide, and glucocorticoids, leading to symptom resolution. The case highlights the importance of considering autoimmune etiologies in hypoglycemia and avoiding unnecessary invasive procedures when clinical and biochemical clues (e.g., insulin to C peptide ratio >1) suggest insulin autoimmune syndrome.

This clinical case report describes an 85 year old woman of Eritrean descent who presented with recurrent postprandial hypoglycemia, weight loss, and episodes of syncope. Initial evaluation revealed Whipple’s triad (hypoglycemia, symptoms, and resolution with glucose administration), prompting investigation for hyperinsulinemic hypoglycemia. Despite elevated insulin and C peptide levels, imaging ruled out insulinoma. The diagnosis of insulin autoimmune syndrome (Hirata disease) was confirmed by the presence of high titer insulin autoantibodies. The patient was managed with a low carbohydrate diet, octreotide, and glucocorticoids, leading to symptom resolution. The case highlights the importance of considering autoimmune etiologies in hypoglycemia and avoiding unnecessary invasive procedures when clinical and biochemical clues (e.g., insulin to C peptide ratio >1) suggest insulin autoimmune syndrome.