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Meleis MM, Vithayaveroj PP, Ebeling-Koning NE, DelBianco JD, Surmaitis RM. Mind the Decimal Point: A Case of Diazoxide Overdose-Induced Ileus. Cureus 2024; 16:e62088. [PMID: 38989349 PMCID: PMC11235150 DOI: 10.7759/cureus.62088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/08/2024] [Indexed: 07/12/2024] Open
Abstract
Diazoxide is the only medication approved by the United States Food and Drug Administration for the treatment of hyperinsulinism-induced hypoglycemia. Overdose is infrequently reported. This case describes a preterm four-week-old male who was prescribed diazoxide and chlorothiazide for perinatal stress-induced hyperinsulinism. The patient presented to the emergency department with feeding intolerance and abdominal distension following an accidental 10-fold diazoxide overdose. On presentation, vital signs were remarkable for tachycardia and intermittent tachypnea. Physical exam revealed a grossly distended abdomen. Laboratory abnormalities included a glucose of 216 mg/dL, sodium of 132 mmol/L, and chloride of 98 mmol/L. Abdominal X-ray interpretation found moderate gaseous distension suggestive of generalized ileus. The patient was admitted to the neonatal intensive care unit (NICU), and a nasogastric tube was placed. He received intravenous dextrose fluids, and enteral feeds were resumed as serial X-rays showed interval improvement. The patient remained in the NICU for several days to monitor bowel movements and resolution of ileus and he was discharged after improvement. While diazoxide overdose is rarely reported, and ileus due to such is documented even less frequently, 10-fold medication dose errors are common among infants. The source of the 10-fold mistake is often decimal points, leading zeros, or trailing zeros. Utilizing the smallest possible syringe for the prescribed dose may reduce the incidence of medication errors.
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Affiliation(s)
- Mostafa M Meleis
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Putt P Vithayaveroj
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Natalie E Ebeling-Koning
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - John D DelBianco
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Ryan M Surmaitis
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
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Shaikh MG, Lucas-Herald AK, Dastamani A, Salomon Estebanez M, Senniappan S, Abid N, Ahmad S, Alexander S, Avatapalle B, Awan N, Blair H, Boyle R, Chesover A, Cochrane B, Craigie R, Cunjamalay A, Dearman S, De Coppi P, Erlandson-Parry K, Flanagan SE, Gilbert C, Gilligan N, Hall C, Houghton J, Kapoor R, McDevitt H, Mohamed Z, Morgan K, Nicholson J, Nikiforovski A, O'Shea E, Shah P, Wilson K, Worth C, Worthington S, Banerjee I. Standardised practices in the networked management of congenital hyperinsulinism: a UK national collaborative consensus. Front Endocrinol (Lausanne) 2023; 14:1231043. [PMID: 38027197 PMCID: PMC10646160 DOI: 10.3389/fendo.2023.1231043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023] Open
Abstract
Congenital hyperinsulinism (CHI) is a condition characterised by severe and recurrent hypoglycaemia in infants and young children caused by inappropriate insulin over-secretion. CHI is of heterogeneous aetiology with a significant genetic component and is often unresponsive to standard medical therapy options. The treatment of CHI can be multifaceted and complex, requiring multidisciplinary input. It is important to manage hypoglycaemia in CHI promptly as the risk of long-term neurodisability arising from neuroglycopaenia is high. The UK CHI consensus on the practice and management of CHI was developed to optimise and harmonise clinical management of patients in centres specialising in CHI as well as in non-specialist centres engaged in collaborative, networked models of care. Using current best practice and a consensus approach, it provides guidance and practical advice in the domains of diagnosis, clinical assessment and treatment to mitigate hypoglycaemia risk and improve long term outcomes for health and well-being.
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Affiliation(s)
- M. Guftar Shaikh
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Angela K. Lucas-Herald
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Antonia Dastamani
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Maria Salomon Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Noina Abid
- Department of Paediatric Endocrinology, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - Sumera Ahmad
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sophie Alexander
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Bindu Avatapalle
- Department of Paediatric Endocrinology and Diabetes, University Hospital of Wales, Cardiff, United Kingdom
| | - Neelam Awan
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Hester Blair
- Department of Dietetics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Roisin Boyle
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Alexander Chesover
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Barbara Cochrane
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Ross Craigie
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Annaruby Cunjamalay
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sarah Dearman
- The Children’s Hyperinsulinism Charity, Accrington, United Kingdom
| | - Paolo De Coppi
- SNAPS, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- NIHR BRC UCL Institute of Child Health, London, United Kingdom
| | - Karen Erlandson-Parry
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Sarah E. Flanagan
- Department of Clinical and Biomedical Science, University of Exeter, Exeter, United Kingdom
| | - Clare Gilbert
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Niamh Gilligan
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Caroline Hall
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Jayne Houghton
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Ritika Kapoor
- Department of Paediatric Endocrinology, Faculty of Medicine and Life Sciences, King’s College London, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Helen McDevitt
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Zainab Mohamed
- Department of Paediatric Endocrinology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Kate Morgan
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jacqueline Nicholson
- Paediatric Psychosocial Service, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Ana Nikiforovski
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Pratik Shah
- Department of Paediatric Endocrinology, Barts Health NHS Trust, Royal London Children’s Hospital, London, United Kingdom
| | - Kirsty Wilson
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sarah Worthington
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Hopkins JJ, Childs AJ, Houghton JAL, Hewat TI, Atapattu N, Johnson MB, Patel KA, Laver TW, Flanagan SE. Hyperinsulinemic Hypoglycemia Diagnosed in Childhood Can Be Monogenic. J Clin Endocrinol Metab 2023; 108:680-687. [PMID: 36239000 PMCID: PMC9931180 DOI: 10.1210/clinem/dgac604] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/05/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Congenital hyperinsulinism (HI) is characterized by inappropriate insulin secretion despite low blood glucose. Persistent HI is often monogenic, with the majority of cases diagnosed in infancy. Less is known about the contribution of monogenic forms of disease in those presenting in childhood. OBJECTIVE We investigated the likelihood of finding a genetic cause in childhood-onset HI and explored potential factors leading to later age at presentation of disease. METHODS We screened known disease-causing genes in 1848 individuals with HI, referred for genetic testing as part of routine clinical care. Individuals were classified as infancy-onset (diagnosed with HI < 12 months of age) or childhood-onset (diagnosed at age 1-16 years). We assessed clinical characteristics and the genotypes of individuals with monogenic HI diagnosed in childhood to gain insights into the later age at diagnosis of HI in these children. RESULTS We identified the monogenic cause in 24% (n = 42/173) of the childhood-onset HI cohort; this was significantly lower than the proportion of genetic diagnoses in infancy-onset cases (74.5% [n = 1248/1675], P < 0.00001). Most (75%) individuals with genetically confirmed childhood-onset HI were diagnosed before 2.7 years, suggesting these cases represent the tail end of the normal distribution in age at diagnosis. This is supported by the finding that 81% of the variants identified in the childhood-onset cohort were detected in those diagnosed in infancy. CONCLUSION We have shown that monogenic HI is an important cause of hyperinsulinism presenting outside of infancy. Genetic testing should be considered in children with persistent hyperinsulinism, regardless of age at diagnosis.
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Affiliation(s)
| | | | - Jayne A L Houghton
- The Genomics Laboratory, Royal Devon University Healthcare NHS foundation Trust, Exeter EX2 5DW, UK
| | - Thomas I Hewat
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Navoda Atapattu
- Paediatric Endocrinology, Lady Ridgeway Hospital, Colombo 00800, Sri Lanka
| | - Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Kashyap A Patel
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
- The Genomics Laboratory, Royal Devon University Healthcare NHS foundation Trust, Exeter EX2 5DW, UK
| | - Thomas W Laver
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Sarah E Flanagan
- Correspondence: Dr. Sarah E. Flanagan, Associate Professor in Genomic Medicine, RILD Building, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK.
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Clinical and genetic characteristics of patients with congenital hyperinsulinism in 21 non-consanguineous families from Serbia. Eur J Pediatr 2021; 180:2815-2821. [PMID: 33770274 DOI: 10.1007/s00431-021-04051-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/07/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
Persistent hypoglycaemia in newborns and infants is most commonly caused by congenital hyperinsulinism (CHI). Most CHI studies report outcomes in children from both consanguineous and non-consanguineous families which can affect the phenotype-genotype analysis. The aim of this study was to analyze characteristics of patients with CHI in 21 non-consanguineous families from Serbia. This retrospective cohort study included a total of 21 patients with CHI treated in the Mother and Child Healthcare Institute of Serbia during the past 20 years. The prevalence of macrosomia at birth was very low in our cohort (4.8%). Median age at presentation was 6 days, with seizures as the presenting symptom in 76% of patients. Only four patients (19%) were diazoxide unresponsive, and eventually underwent pancreatectomy. Genetic testing was performed in 15 patients and genetic diagnosis was confirmed in 60%, with all patients being heterozygous for detected mutations. The ABCC8 gene mutations were detected in 55.6%, GLUD1 in three patients (33.3%) with HIHA syndrome and one patient had HNF4A gene mutation and unusual prolonged hyperglycaemia lasting 6 days after diazoxide cessation. Neurodevelopmental deficits persisted in 33% of patients.Conclusion: This is the first study regarding CHI patients in Serbia. It suggests that in countries with low consanguinity rate, majority of CHI patients are diazoxide responsive. The most common mutations were heterozygous ABCC8, followed by GLUD1 and HNF4A mutations, suggesting the potential benefit of population-tailored genetic analysis approach, targeting the mutations causing CHI via dominant inheritance model in regions with low consanguinity rates. What is Known: • Persistent hypoglycaemia during infancy and early childhood is most commonly caused by congenital hyperinsulinism (CHI). • Consanguinity is a very important factor regarding the genetics and phenotype of CHI, increasing the risk of autosomal recessive genetic disorders, including the severe, diazoxide-unresponsive forms caused by recessive inactivating mutations in ABCC8 and KCNJ11. What is New: • Results of the present study which included CHI patients from 21 non-consanguineous families suggest that in countries with low consanguinity rates, majority of CHI patients can be diazoxide responsive, with most common mutations being heterozygous ABCC8, followed by GLUD1 and HNF4A mutations. • Unusually prolonged hyperglycaemic reaction to diazoxide treatment in a patient with HNF4A mutation was also described in the present study.
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Laimon W, Aboelenin HM, El Tantawi NT. Clinical characteristics, outcome, and predictors of neurological sequelae of persistent congenital hyperinsulinism: A single tertiary center experience. Pediatr Diabetes 2021; 22:388-399. [PMID: 33528087 DOI: 10.1111/pedi.13186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/09/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022] Open
Abstract
AIM Congenital hyperinsulinism (CHI) is a heterogeneous disease with variable genetic etiology, histopathology, and clinical phenotype. This study aims to describe the clinical characteristics of persistent CHI and evaluate long-term neurological outcome and its risk factors in a cohort of Egyptian children. METHODS Clinical, genetic, and biochemical data of 42 patients with CHI were collected. Patients were invited for neurological assessment, electroencephalogram, and magnetic resonance imaging of the brain. RESULTS ABCC8 mutation was found in (61%) of cases who underwent genetic testing (17/28). Five cases with homozygous biparental ABCC8 mutation responded to combined diazoxide and octreotide without needing surgery. Seven out of twenty-one patients who had pancreatectomy (33%) developed diabetes after a median period of 4.8 (range:1-10) years following surgery. Fifty-five percent of our patients had neurodevelopmental impairment at follow-up. Logistic regression analysis has shown that delayed referral to tertiary centre for more than 8 days, delayed diagnosis of CHI for more than 14 days and hospital admission for more than 30 days, are significant predictors of unfavorable neurological sequelae in CHI; (OR = 12.7 [2.56], p = 0.001), (OR = 12.7 [2.9-56], p = 0.001), and (OR = 3.8 [0.14.5], p = 0.043), respectively. CONCLUSIONS ABCC8 mutation was the commonest genetic mutation underlying CHI in this study group. CHI cases with biparental homozygous ABCC8 mutation may show response to combined octreotide and diazoxide therapy. More than half of our patients had neurodevelopmental impairment at follow-up. Delayed referral to expert centre, delayed diagnosis and longer hospital stay are significant predictors of neurological disability in CHI cases.
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Affiliation(s)
- Wafaa Laimon
- Pediatric Endocrinology and Diabetes Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Hadil Mohamed Aboelenin
- Pediatric Endocrinology and Diabetes Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Noha T El Tantawi
- Pediatric Neurology Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
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Haris B, Saraswathi S, Hussain K. Somatostatin analogues for the treatment of hyperinsulinaemic hypoglycaemia. Ther Adv Endocrinol Metab 2020; 11:2042018820965068. [PMID: 33329885 PMCID: PMC7720331 DOI: 10.1177/2042018820965068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a biochemical finding of low blood glucose levels due to the dysregulation of insulin secretion from pancreatic β-cells. Under normal physiological conditions, glucose metabolism is coupled to β-cell insulin secretion so that blood glucose levels are maintained within the physiological range of 3.5-5.5 mmol/L. However, in HH this coupling of glucose metabolism to insulin secretion is perturbed so that insulin secretion becomes unregulated. HH typically occurs in the neonatal, infancy and childhood periods and can be due to many different causes. Adults can also present with HH but the causes in adults tend to be different. Somatostatin (SST) is a peptide hormone that is released by the delta cells (δ-cells) in the pancreas. It binds to G protein-coupled SST receptors to regulate a variety of location-specific and selective functions such as hormone inhibition, neurotransmission and cell proliferation. SST plays a potent role in the regulation of both insulin and glucagon secretion in response to changes in glucose levels by negative feedback mechanism. The half-life of SST is only 1-3 min due to quick degradation by peptidases in plasma and tissues. Thus, a direct continuous intravenous or subcutaneous infusion is required to achieve the therapeutic effect. These limitations prompted the discovery of SST analogues such as octreotide and lanreotide, which have longer half-lives and therefore can be administered as injections. SST analogues are used to treat different forms of HH in children and adults and therapeutic effect is achieved by suppressing insulin secretion from pancreatic β-cells by complex mechanisms. These treatments are associated with several side effects, especially in the newborn period, with necrotizing enterocolitis being the most serious side effect and hence SS analogues should be used with extreme caution in this age group.
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Affiliation(s)
- Basma Haris
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Saras Saraswathi
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Professor of Paediatrics, Weill Cornell Medicine-Qatar, Division Chief – Endocrinology, Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, OPC, C6-340 |PO Box 26999, Al Luqta Street, Education City North Campus, Doha, Qatar
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