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An elderly man with pleural effusion and abnormal behaviour

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A 76 year old man, who had been an asbestos insulation worker, presented with a four month history of right sided severe diffuse chest pain, breathlessness on exertion, and weight loss of 10 kg. He had recurrent episodes of lethargy, agitation, and abnormal behaviour. These episodes were partially relieved by eating a high carbohydrate diet. On admission he was found to be unrousable. His Glasgow coma scale score was 7/15 with no focal neurological deficit. He had clubbing and right sided massive pleural effusion and contracted right hemithorax with mediastinal shift to same side. Full blood counts, urea, electrolytes, liver function tests, and serum calcium were normal. Plasma glucose concentrations were 1.5 mmol/l. He was given 50 ml of 50% dextrose intravenous with correction of his hypoglycaemia and he became conscious. A chest radiograph (posteroanterior) showed complete opacification of right hemithorax (fig 1). Computer tomography of his thorax revealed right pleural thickening encasing the collapsed right lung and contraction of right hemithorax. Pleural aspiration revealed a viscous jelly-like exudate with “atypical” mesothelial cells and high hyaluronidase levels. Pleural biopsy revealed a malignant sarcomatoid mesothelioma. The subsequent week was characterised by rapid reaccumulation of pleural effusion in spite of repeated aspirations. The hypoglycaemic episodes increased in frequency though he was on approximately 380 g of glucose intravenously per day with intramuscular glucagon intermittently.

Figure 1

Chest radiograph (posteroanterior) showing complete opacification of right hemithorax.  

Plasma glucose concentrations were 0.8 mmol/l, insulin (<25 pmol/l), C peptide (<75 pmol/l), and β-hydroxybutyrate (<20 mmol/l) were undetectable, serum growth hormone was 0.9 mU/l. Insulin-like growth factor-II (IGF-I) concentration was 0.16 U/ml (reference range 0.4–2.0), serum IGF-II concentration was raised at 2.0 U/ml, and ratio of IGF-I: IGF-II was 0.08 (normal >0.2). “Big” IGF-II concentration was 20.8 nmol/l (0–14.4) and IGF binding protein-3 (IGFBP-3) concentrations were 2.2 mg/l (2.0–4.8). A short tetracosactrin (Synacthen) test was normal.

Questions

(1)
What is the cause of this patient's hypoglycaemia?
(2)
What pharmacological agents may alleviate his hypoglycaemia?
(3)
What is the role of surgery in management of this patient?

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