Unmasking an insulinoma: recurrent Hypoglycemia in a young patient following GLP-1 receptor agonist therapy -A case report.

BACKGROUND: Insulinomas are rare, typically benign pancreatic neuroendocrine tumors that cause endogenous hyperinsulinemic hypoglycemia. While usually diagnosed in middle age, their presence in young adults may suggest hereditary syndromes, such as MEN1. While semaglutide and other GLP-1 receptor agonists rarely cause hypoglycemia, they can unmask tumors secreting insulin. CASE PRESENTATION: A 25-year-old woman with obesity and polycystic ovary syndrome (PCOS) developed severe hypoglycemia (35 mg/dL) after starting semaglutide. She did not respond to IV dextrose. Labs showed hyperinsulinemia (77.5 mU/L) and elevated C-peptide (19.53 ng/mL). Imaging revealed a pancreatic tail mass, pituitary microadenoma, and ovarian teratoma, raising concern for MEN1. She underwent distal pancreatectomy, splenectomy, and right salpingo-oophorectomy. Glycemia normalized postoperatively. Pathology confirmed a grade 1 pancreatic neuroendocrine tumor (Ki-67 < 1%). CONCLUSION: This case emphasizes that hypoglycemia occurring during GLP-1 receptor agonist therapy is not always a drug-related side effect but may result from unmasking of an underlying insulinoma.