Review Question - QID 108656

A 44-year-old female is brought to the emergency room after losing consciousness at a shopping mall. Her husband states that they were shopping when the patient appeared sweaty and tremulous, became confused, then collapsed. She was unconscious for 5 minutes until a paramedic arrived. Fingerstick glucose at that time was 31 mg/dL and intramuscular glucagon was administered. The patient regained consciousness as she was being transported to the ambulance. On arrival in the emergency room, she is conscious but sleepy. She is able to report that her last meal prior to the mall was 5 hours ago. Her husband notes that over the last 3 months, she has complained of headaches and a milky discharge from both breasts, as well as nausea if she goes too long without eating. She works as an inpatient nurse and was exposed to tuberculosis 10 years ago but was adequately treated. Because she was adopted as an infant, her family history is unknown. Temperature is 98.4°F (36.9°C), blood pressure is 101/59 mmHg, pulse is 88/min, and respiration is 14/min. Preliminary lab values are shown below:

Plasma:
Glucose: 54 mg/dL
Insulin: 29 pmol/L (normal < 19 pmol/L)
C-peptide: 272 pmol/L (normal < 200 pmol/L)
Proinsulin: 8 pmol/L (normal < 5 pmol/L)
ß-hydroxybutyrate: 1.2 mmol/L (normal > 2.7 mmol/L after fasting)

Which of the following is the most likely cause of this patient’s hypoglycemic episode?