Key Clinical MessageSpontaneously oscillating thyroid function in Graves’ disease is a rare phenomenon. Switching between TSH receptor stimulating antibodies (TSAb) and TSH receptor blocking antibodies (TBAb) most likely accounts for presentations of alternating hyperthyroidism and hypothyroidism. To achieve stability of thyroid function, definitive therapy is recommended to remove the pathological thyroid.

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Initial R-HDU management is an effective option in selected HRF to reduce ICU demand, although mortality and clinical deterioration despite NIV are more common than in HCRF.

Objective: Adult nesidioblastosis is characterized by endogenous hyperinsulinemia typically causing post-prandial hypoglycemia, and most commonly occurs post-Roux-en-Y gastric bypass. Methods: We report a unique case of nesidioblastosis occurring in a 67-year-old female. Results: A 5-year history of symptomatic hypoglycemia occurred in a patient with short bowel syndrome and type 2 diabetes mellitus (T2DM) managed previously with a glucagon-like peptide 1 (GLP-1) agonist, which achieved significant weight loss. Continuous glucose monitoring captured 42 hypoglycemia episodes in a 2-week period, and following an oral glucose tolerance test there was the suggestion of a hyperinsulinemia state. She was managed with an open distal pancreatectomy, and subsequently required medical therapy to maintain euglycemia. Conclusion: We present the first case of nesidioblastosis occurring in a patient with short bowel syndrome, pre-existing T2DM managed with a GLP-1 agonist which achieved significant weight loss, all of which we speculate could have predisposed to hypoglycemia and development of nesidioblastosis.