1
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Teoli J, Chikh K, Jouini-Bouhamri R, Charriere S, Fabien N, Raverot V. When discordant insulin and C-peptide levels lead to a medical diagnosis in a patient with transient hypoglycemia: Varying degrees of interference of insulin-antibody complexes on three insulin immunoassays. Heliyon 2024; 10:e34009. [PMID: 39071705 PMCID: PMC11280251 DOI: 10.1016/j.heliyon.2024.e34009] [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: 12/13/2023] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/30/2024] Open
Abstract
Background Determining the cause of hypoglycemia partly relies on blood insulin and C-peptide assays. Although the pancreatic secretion of these peptides is equimolar, discrepancies in their concentrations may occur. Case presentation We report the case of a 73-year-old woman with type 2 diabetes mellitus (T2DM) and a history of gastric bypass. The T2DM was initially treated with insulin analogs, which were interrupted due to transient hypoglycemia episodes three years before hospitalization in our endocrinology department. During this hospitalization, the most common etiologies of hypoglycemia were excluded. Fasting insulin level was high (190 mIU/L, reference values (RV): 5-25) on Architect i2000 (an assay recognizing insulin analogs) despite normal blood C-peptide (4.5 μg/L, RV: 0.8-5.2) and slight hypoglycemia (4.5 mmol/L, RV: 4.6-6.1). Insulin level using the Elecsys assay (an assay with low sensitivity to insulin analogs) was very high (>1000 mIU/L, RV: 2.6-24.9). This pattern was observed on several samples, including some taken during a fasting test. Insulin level was only slightly increased using the Mercodia iso-insulin ELISA kit (an assay recognizing insulin analogs). These results excluded an exogenous insulin intake and were suggestive of an interference on insulin assays. To explore the latter possibility, free anti-insulin antibodies were measured and found strongly positive. The presence of interfering insulin-antibody complexes was further investigated using gel filtration chromatography, polyethylene glycol precipitation, and dilution test. Based on these findings, an insulin autoimmune syndrome (IAS) was suspected to cause the hypoglycemic episodes observed. Conclusion Although a discrepancy between blood insulin and C-peptide levels points to insulin analog intake, IAS should also be considered, particularly in a patient with transient hypoglycemia. IAS is characterized by the presence of insulin-antibody complexes, which can induce varying degrees of interference on insulin immunoassays and may lead to discordant insulin and C-peptide levels according to the insulin immunoassay used.
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Affiliation(s)
- Jordan Teoli
- Laboratoire de Biologie Médicale Multisites, Service de Biochimie et Biologie Moléculaire, UM Biologie Endocrinienne, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Bron, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Institut Cellule Souche et Cerveau (SBRI), Unité INSERM 1208, Centre de Recherche INSERM, Bron, France
| | - Karim Chikh
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire de biologie Médicale Multisites, Service de Biochimie et Biologie Moléculaire, UM Biologie Endocrinienne, Centre de Biologie et Pathologie Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Laboratoire CarMen, UMR INSERM U1060/INRAE U1397, Université Claude Bernard Lyon 1, Pierre Bénite, France
| | - Ryme Jouini-Bouhamri
- Fédération d'Endocrinologie, Maladies Métaboliques, Diabète, et Nutrition, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Sybil Charriere
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire CarMen, UMR INSERM U1060/INRAE U1397, Université Claude Bernard Lyon 1, Pierre Bénite, France
- Fédération d'Endocrinologie, Maladies Métaboliques, Diabète, et Nutrition, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Nicole Fabien
- Service d'immunologie, Centre de Biologie et Pathologie Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Véronique Raverot
- Laboratoire de Biologie Médicale Multisites, Service de Biochimie et Biologie Moléculaire, UM Biologie Endocrinienne, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Bron, France
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2
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Okumura H, Inaba S, Kawashima A, Shimizu T. Insulin Autoimmune Syndrome: A Case Report Highlighting Diagnostic Pitfalls. Cureus 2024; 16:e64130. [PMID: 39119412 PMCID: PMC11307240 DOI: 10.7759/cureus.64130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/10/2024] Open
Abstract
Insulin autoimmune syndrome (IAS) is characterized by spontaneous hyperinsulinemic hypoglycemia and the presence of insulin autoantibodies in high titers without exogenous insulin use. The C-peptide level during a hypoglycemia episode is useful for differentiating spontaneous hypoglycemia. Generally, low C-peptides are suspicious for exogenous insulin administration. We report a 47-year-old male nurse who presented with an initial episode of hypoglycemia. Despite the pattern of hyperinsulinemic hypoglycemia and low C-peptide, he was diagnosed with IAS based on the presence of insulin autoantibodies. This case underscores the importance of suspecting IAS in non-diabetic adults with hypoglycemia, even in the setting of low C-peptide levels.
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Affiliation(s)
- Hisatoshi Okumura
- Department of Emergency Medicine, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Satoshi Inaba
- Department of General Medicine, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Atsushi Kawashima
- Department of General Medicine, Fukuchiyama City Hospital, Fukuchiyama, JPN
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Mibu, JPN
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3
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Perri A, Fattore S, Sbordone A, Viti L, Pitocco D, Vento G. Secondary Hirata Syndrome in a Neonate: Practical Approach and Management. JCEM CASE REPORTS 2024; 2:luae109. [PMID: 38952701 PMCID: PMC11216324 DOI: 10.1210/jcemcr/luae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Indexed: 07/03/2024]
Abstract
Hirata disease, also known as insulin autoimmune syndrome (IAS), is a rare cause of hypoglycemia, due to the presence of insulin autoantibodies (IAA) in the circulating blood. These antibodies are immunoglobulin G (IgG), making placental transfer to the fetus possible. To our knowledge, no reports of IAS have been previously described in the neonatal population. We present a case report of hypoglycemia due to a secondary IAS in a neonate and discuss the management and treatment of the disease.
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Affiliation(s)
- Alessandro Perri
- Department of Woman and Child Health Sciences, Child Health Area, University Hospital Agostino Gemelli, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Lazio, Italy
| | - Simona Fattore
- Department of Woman and Child Health Sciences, Child Health Area, University Hospital Agostino Gemelli, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Lazio, Italy
| | - Annamaria Sbordone
- Department of Woman and Child Health Sciences, Child Health Area, University Hospital Agostino Gemelli, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Lazio, Italy
| | - Luca Viti
- Diabetes Care Unit, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Dario Pitocco
- Diabetes Care Unit, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health Sciences, Child Health Area, University Hospital Agostino Gemelli, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Lazio, Italy
- Department of Woman and Child Health Sciences, Child Health Area, Catholic University of Sacred Heart Seat of Rome, 00168 Rome, Lazio, Italy
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4
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Milionis C, Ilias I, Lekkou A, Venaki E, Koukkou E. Future clinical prospects of C-peptide testing in the early diagnosis of gestational diabetes. World J Exp Med 2024; 14:89320. [PMID: 38590302 PMCID: PMC10999065 DOI: 10.5493/wjem.v14.i1.89320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 03/19/2024] Open
Abstract
Gestational diabetes is typically diagnosed in the late second or third trimester of pregnancy. It is one of the most common metabolic disorders among expectant mothers, with potential serious short- and long-term complications for both maternal and offspring health. C-peptide is secreted from pancreatic beta-cells into circulation in equimolar amounts with insulin. It is a useful biomarker to estimate the beta-cell function because it undergoes negligible hepatic clearance and consequently it has a longer half-life compared to insulin. Pregnancy induces increased insulin resistance due to physiological changes in hormonal and metabolic homeostasis. Inadequate compensation by islet beta-cells results in hyperglycemia. The standard oral glucose tolerance test at 24-28 wk of gestation sets the diagnosis. Accumulated evidence from prospective studies indicates a link between early pregnancy C-peptide levels and the risk of subsequent gestational diabetes. Elevated C-peptide levels and surrogate glycemic indices at the beginning of pregnancy could prompt appropriate strategies for secondary prevention.
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Affiliation(s)
- Charalampos Milionis
- Department of Endocrinology, Diabetes, and Metabolism, ‘Elena Venizelou’ General Hospital, Athens 11521, Greece
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes, and Metabolism, ‘Elena Venizelou’ General Hospital, Athens 11521, Greece
| | - Anastasia Lekkou
- Department of Endocrinology, Diabetes, and Metabolism, ‘Elena Venizelou’ General Hospital, Athens 11521, Greece
| | - Evangelia Venaki
- Department of Endocrinology, Diabetes, and Metabolism, ‘Elena Venizelou’ General Hospital, Athens 11521, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes, and Metabolism, ‘Elena Venizelou’ General Hospital, Athens 11521, Greece
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Low CK, Wong HC, Apparow S, Yong SL. Insulin Autoimmune Syndrome - An After-Meal Roller Coaster Ride. J ASEAN Fed Endocr Soc 2024; 39:125-128. [PMID: 38863913 PMCID: PMC11163323 DOI: 10.15605/jafes.039.01.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/05/2023] [Indexed: 06/13/2024] Open
Abstract
Hypoglycemic disorders are rare in persons without diabetes, and clinical evaluation to identify its etiology can be challenging. We present a case of insulin autoimmune syndrome induced by carbimazole in a middle-aged Chinese man with underlying Graves' disease, which was managed conservatively with a combination of dietary modification and alpha-glucosidase inhibitor.
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Affiliation(s)
- Chee Koon Low
- Endocrine Unit, Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
| | - Hui Chin Wong
- Endocrine Unit, Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
| | - Saraswathy Apparow
- Endocrine Unit, Biochemical Genomic Research Centre, Institute for Medical Research, Kuala Lumpur, Malaysia
| | - Sy Liang Yong
- Endocrine Unit, Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
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Kumar V, Gala D, Rafi I, Shah M, Marowa S, Kaul D, Lukose S, Kazeem S. Autoimmune Hypoglycemia With Anti-Insulin Autoantibodies in an Eighty-One-Year-Old Woman Without Apparent Risk Factors. AACE Clin Case Rep 2023; 9:146-148. [PMID: 37736322 PMCID: PMC10509373 DOI: 10.1016/j.aace.2023.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/10/2023] [Accepted: 04/21/2023] [Indexed: 09/23/2023] Open
Abstract
Background/Objective Insulin autoimmune syndrome (IAS) is a very rare cause of hypoglycemia presenting with recurrent fasting or postprandial hypoglycemia episodes with elevated serum insulin levels and insulin autoantibodies. The objective of this case is to highlight the importance of considering IAS in patients with hypoglycemia. Case Report We present a case of an 81-year-old female who presented with symptoms of hypoglycemia. She was found to have hyperinsulinemic hypoglycemic episodes without any apparent risk factors for IAS. She had positive-insulin autoantibodies in her serum leading to the diagnosis of IAS. Acutely, hypoglycemia was managed with D50 pushes, oral glucose, and glucagon injection. Discussion Patients who present with hypoglycemia due to endogenous hyperinsulinemia should have IAS considered as a possible differential diagnosis. Insulin autoantibodies are measured as the gold standard diagnostic test for IAS. Foods with a low glycemic index are the primary treatment for IAS. Conclusion This case presentation highlights the importance of considering IAS as a differential diagnosis in patients presenting with hypoglycemia secondary to hyperinsulinemia, even in the absence of apparent risk factors.
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Affiliation(s)
- Vikash Kumar
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Dhir Gala
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
| | - Ibnul Rafi
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
| | - Mili Shah
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
| | - Sabrin Marowa
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Diksha Kaul
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Simon Lukose
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Saka Kazeem
- Department of Endocrinology, The Brooklyn Hospital Center, Brooklyn, New York
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7
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Zhou L, Luo Y, Wang Y, Cheng Y, Zhang R, Zhang S, Gong S, Han X, Ji L. The clinical implications of fasting serum insulin levels in patients with insulin-treated type 2 diabetes: a cross-sectional survey. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2023; 4:1172208. [PMID: 37324170 PMCID: PMC10266272 DOI: 10.3389/fcdhc.2023.1172208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
Objective This study aimed to investigate the clinical implications of fasting serum insulin (FINS) levels in subjects with type 2 diabetes who were receiving insulin therapy. Methods A total of 1,553 subjects with type 2 diabetes [774 subjects who had never received insulin treatment (N-INS) and 779 subjects who were receiving insulin therapy (constant insulin treatment, C-INS)] admitted to the Department of Endocrinology and Metabolism of Peking University People's Hospital were enrolled in this study. Their FINS levels were measured and those with hyperinsulinemia were identified. The underlying mechanisms of hyperinsulinemia were revealed by measuring insulin antibodies (IAs) and analyzing changes in FINS levels before and after polyethylene glycol (PEG) precipitation. In addition, the clinical characteristics of patients with different types of hyperinsulinemia were compared. Results Higher FINS levels and a higher incidence (43.8%, 341/779) of hyperinsulinemia (FINS > 15μIU/mL) were observed in subjects with C-INS than in subjects with N-INS. Among subjects with C-INS and hyperinsulinemia, 66.9% (228/341) were IAs positive, and the incidence of IAs was found to be positively associated with FINS level. By performing PEG precipitation, we found that all subjects without IAs (i.e., those with real hyperinsulinemia) and 31.1% of subjects (71/228) with IAs (i.e., those with both real and IAs-related hyperinsulinemia) still had hyperinsulinemia after PEG precipitation, whereas FINS levels in the other 68.9% of subjects (157/228) with IAs were normal (IAs-related hyperinsulinemia) after PEG precipitation. Comparisons between the groups showed that subjects with real hyperinsulinemia showed more obvious insulin resistance characteristics, including higher lipid levels, BMIs, and homoeostasis model assessment2-estimated insulin resistance (HOMA2-IR) index, and were more likely to have hypertension, obesity, and metabolic syndromes (p < 0.05). However, the risk of hypoglycemia and glucose variability increased significantly in subjects with IAs compared with those without IAs. A cutoff of FINS to serum C-peptide ratio (≥ 9.3μIU/ng) could be used to screen IAs in clinical practice with 83.3% sensitivity and 70% specificity. Conclusions It is necessary to measure FINS in subjects with C-INS to distinguish between types of hyperinsulinemia, which should help to tailor treatment regimens.
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Affiliation(s)
- Lingli Zhou
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Yingying Luo
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Yan Wang
- Department of Endocrinology and Metabolism, People’s Hospital of Deyang City, Deyang, Sichuan, China
| | - Yao Cheng
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Rui Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Simin Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Siqian Gong
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Xueyao Han
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
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8
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Palani G, Stortz E, Moheet A. Clinical Presentation and Diagnostic Approach to Hypoglycemia in Adults Without Diabetes Mellitus. Endocr Pract 2023; 29:286-294. [PMID: 36464132 DOI: 10.1016/j.eprac.2022.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/24/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To review the clinical presentation, causes, and diagnostic approach to spontaneous hypoglycemia in adults without diabetes mellitus. METHODS A literature review was performed using the PubMed and Google Scholar databases. RESULTS Hypoglycemia is uncommon in people who are not on glucose-lowering medications. Under normal physiologic conditions, multiple neural and hormonal counterregulatory mechanisms prevent the development of abnormally low levels of plasma glucose. If spontaneous hypoglycemia is suspected, the Whipple triad should be used to confirm hypoglycemia before pursuing further diagnostic workup. The Whipple criteria include the following: (1) low levels of plasma glucose, (2) signs or symptoms that would be expected with low levels of plasma glucose, and (3) improvement in those signs or symptoms when the level of plasma glucose increases. Spontaneous hypoglycemia can be caused by conditions that cause endogenous hyperinsulinism, including insulinoma, postbariatric hypoglycemia, and noninsulinoma pancreatogenous hypoglycemia. Spontaneous hypoglycemia can also be seen with critical illness, hepatic or renal dysfunction, hormonal deficiency, non-diabetes-related medications, and non-islet cell tumors. The initial diagnostic approach should begin by obtaining a detailed history of the nature and timing of the patient's symptoms, medications, underlying comorbid conditions, and any acute illness. A laboratory evaluation should be conducted at the time of the spontaneous symptomatic episode. Supervised tests such as a 72-hour fast or mixed-meal test may be needed to recreate the situation under which the patient is likely to experience symptoms. CONCLUSION We provide an overview of the physiology of counterregulatory response to hypoglycemia, its causes, and diagnostic approaches to spontaneous hypoglycemia in adults.
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Affiliation(s)
- Gurunanthan Palani
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ethan Stortz
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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9
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Lin M, Chen Y, Ning J. Insulin Autoimmune Syndrome: A Systematic Review. Int J Endocrinol 2023; 2023:1225676. [PMID: 36844104 PMCID: PMC9946739 DOI: 10.1155/2023/1225676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
Insulin autoimmune syndrome (IAS) is a rare endocrine disorder characterized by recurrent episodes of severe hypoglycemia, markedly elevated serum insulin, and positive insulin autoantibodies. In recent years, various countries have reported it one after another. It can be seen that we must pay attention to this disease. The diagnosis of IAS is challenging, requiring a careful workup aimed at excluding other causes of hyperinsulinemic hypoglycemia. High levels of insulin autoantibodies are found in patients, and C-peptide is not parallel to insulin, which could be diagnostic. IAS is a self-limiting disease with a good prognosis. Its treatment mainly includes symptomatic supportive treatment, such as adjusting the diet and using acarbose and other drugs to delay the absorption of glucose to prevent hypoglycemia. For patients with severe symptoms, available treatments may include drugs that reduce pancreatic insulin secretion (such as somatostatin and diazoxide), immunosuppressants (glucocorticoids, zaprin, and rituximab), and even plasma exchange to remove autoantibodies from the body. This review provides a comprehensive analysis of the epidemiology, pathogenesis, clinical manifestations, diagnosis and identification, and monitoring and treatment management of IAS.
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Affiliation(s)
- MingXu Lin
- Department of Endocrinology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen 518110, Guangdong, China
| | - YuHua Chen
- Guangdong Medical University, Zhanjiang 524000, Guangdong, China
- Department of Endocrinology, Longgang District People's Hospital of Shenzhen, Shenzhen 518172, Guangdong, China
| | - Jie Ning
- Department of Endocrinology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen 518110, Guangdong, China
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10
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Hua KF, Jing BY, Wu YH. The Application of the Insulin to C-Peptide Molar Ratio (ICPR) in Primary Screening for Insulin Antibodies in Type 2 Diabetes Mellitus Patients: A Further Quantitative Study on the Relationship Between ICPR and Insulin Antibodies. Diabetes Metab Syndr Obes 2023; 16:1121-1132. [PMID: 37122678 PMCID: PMC10134342 DOI: 10.2147/dmso.s404222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023] Open
Abstract
Purpose This study aimed to further quantify the relationship between insulin antibodies (IAs) and the 2-hour insulin to C-peptide molar ratio (2h-ICPR) using a multiple linear regression model in T2DM patients. Methods A total of 274 T2DM patients from April 2019 to December 2022 in Xiang'an Hospital of Xiamen University were included in this study. Multiple Linear Model Fitting was conducted on the candidate independent variables (age, BMI, HbA1c, and 2h-ICPR) for the multiple linear regression. The linear relationship between insulin antibodies (IAs) and the significant independent variables was presented by making multiple linear regression equations. Results The total demographic characteristics of the included patients were as follows: age (51.92±13.10 years), BMI (24.94±3.99 kg/m2), HbA1c (9.70±2.39%), 2h-ICPR (0.12±0.11), and IAs (0.37±1.12COI). Linear relationships of independent variables: age (r=0.163, p=0.007), 2h-ICPR (r=0.259, p=0.001), BMI (r=0.007, p=0.907) and 2h-ICPR (r=0.092, p=0.129). Multiple linear regression: age (unstandardized β=0.014, 95% CI: 0.004-0.024, p=0.004), 2h-ICPR (unstandardized β=2.758, 95% CI: 1.555-3.962, p≤0.001). The regression equation: . Conclusion The quantitative relationship between 2h-ICPR and insulin antibodies was . 2h-ICPR can be a preliminary screening indicator for insulin antibody testing in patients with type 2 diabetes.
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Affiliation(s)
- Kai-Fang Hua
- Department of Endocrinology, Xiang’an Hospital of Xiamen University, Xiamen, Fujian, People’s Republic of China
- School of Medicine, Xiamen University, Xiamen, Fujian, People’s Republic of China
| | - Bo-Yang Jing
- Hai Yuan College, Kunming Medical University, Kunming, Yunnan, People’s Republic of China
| | - Yan-Hui Wu
- Department of Endocrinology, Xiang’an Hospital of Xiamen University, Xiamen, Fujian, People’s Republic of China
- National Metabolic Management Center, Xiang’an Hospital of Xiamen University, Xiamen, Fujian, People’s Republic of China
- Correspondence: Yan-Hui Wu, Department of Endocrinology, Xiang’an Hospital of Xiamen University, 2000 Xiang’ an East Road, Xiamen, Fujian, 361102, People’s Republic of China, Tel +8613089998806, Email
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11
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Affiliation(s)
- Amy W Baughman
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Nancy J Wei
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Peter F Hahn
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Brenna W Casey
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - M Lisa Zhang
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
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12
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Zhu Q, Zhao H, Qiu W, Wu F, Qian C, Yang Y, Kang Y, Zheng F, Zhou J. Case Report: Recurrent Autoimmune Hypoglycemia Induced by Non-Hypoglycemic Medications. Front Immunol 2022; 13:855350. [PMID: 35935967 PMCID: PMC9352986 DOI: 10.3389/fimmu.2022.855350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
We present a case of recurrent autoimmune hypoglycemia induced by non-hypoglycemic agents. We review reported cases of autoimmune hypoglycemia related to non-hypoglycemic agents, and discuss the effects of different detection methods for insulin autoantibodies on the results obtained. We aim to provide information for clinicians and a warning for medication usage. Considering the increasing number of clopidogrel-induced AIH cases and the hypoglycemia-induced increase in the risk of cardiovascular events, we recommend that cardiovascular disease patients being treated with clopidogrel be informed of this rare side effect and that clinicians be vigilant for the possibility of autoimmune hypoglycemia in this patient population.
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Affiliation(s)
- Qiuping Zhu
- Department of Endocrinology and Metabolism, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Endocrinology, Haining People’s Hospital, Haining, China
| | - Hanxin Zhao
- Department of Endocrinology and Metabolism, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Qiu
- Department of Endocrinology, Huzhou Central Hospital, Huzhou, China
| | - Fang Wu
- Department of Endocrinology and Metabolism, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chungen Qian
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
- Reagent R&D Center, Shenzhen YHLO Biotech Co., Ltd, Shenzhen, China
| | - Yonghong Yang
- Reagent R&D Center, Shenzhen YHLO Biotech Co., Ltd, Shenzhen, China
| | - Ye Kang
- Reagent R&D Center, Shenzhen YHLO Biotech Co., Ltd, Shenzhen, China
| | - Fenping Zheng
- Department of Endocrinology and Metabolism, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiaqiang Zhou
- Department of Endocrinology and Metabolism, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Jiaqiang Zhou,
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Haverkamp GLG, Ijzerman RG, Kooter J, Krul-Poel YHM. The After-Dinner Dip. N Engl J Med 2022; 386:2130-2136. [PMID: 35648706 DOI: 10.1056/nejmcps2106883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Gertrud L G Haverkamp
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
| | - Richard G Ijzerman
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
| | - Jos Kooter
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
| | - Yvonne H M Krul-Poel
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
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Oest L, Roden M, Müssig K. Comparison of patient characteristics between East Asian and non-East Asian patients with insulin autoimmune syndrome. Clin Endocrinol (Oxf) 2022; 96:328-338. [PMID: 34778997 DOI: 10.1111/cen.14634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Insulin autoimmune syndrome (IAS) is the third most common cause of spontaneous hypoglycaemia in Japan but very rare in the rest of the world. We aimed to identify factors, which are associated with the occurrence of IAS and which may differ between East Asian and non-East Asian patients. DESIGN A PubMed search using the search terms 'insulin autoimmune syndrome' and 'Hirata disease' revealed a total of 287 reports of IAS cases, including one previously unpublished own case. RESULTS Mean age (±standard deviation) was 52 ± 19 years in East Asian and 54 ± 21 years in non-East Asian patients (p > .05). In both groups, there were more females. Mean body mass index was lower in East Asian than in non-East Asian patients (23.0 ± 4.3 vs. 27.1 ± 5.6 kg/m2 , p < .0001). Postprandial hypoglycaemia was more common in non-East Asian patients (p < .05). East Asian patients took more frequently antithyroid medications and non-East Asian patients angiotensin-converting enzyme (ACE) inhibitors (both p < .0001). Graves' disease and other autoimmune diseases were more frequently observed in East Asian patients (both p < .01). Parameters of glucose metabolism were comparable in both groups, independent of diabetes diagnosis (p > .05), except for insulin that was higher in East Asian compared to non-East Asian metabolically healthy patients (p < .01). Human leukocyte antigen (HLA)-DRB1*0406 was the most frequent HLA-type in East Asian patients (p < .0001), whereas DRB1*0403 and *0404 were more frequent in non-East Asian patients (both p < .05). Non-East Asian patients received more secondary treatments, including plasmapheresis and rituximab, whereas medication discontinuation was more common in East Asian patients (all p < .05). Outcome was similar in both groups (p > .05). CONCLUSIONS Factors associated with IAS markedly differ between East Asian and non-East Asian patients, with autoimmune disorders, particularly Graves' disease, antithyroid medications, and HLA-DRB1*0406 more prevalent in East Asian patients and cardiovascular and plasma cell diseases, ACE inhibitors and HLA-DRB1*0403 more prevalent in non-East Asian patients.
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Affiliation(s)
- Lisa Oest
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
| | - Karsten Müssig
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
- Department of Internal Medicine and Gastroenterology, Niels Stensen Hospitals, Franziskus Hospital Harderberg, Georgsmarienhütte, Germany
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15
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Hua KF, Zhang MY, Zhang Y, Ren BJ, Wu YH. Characteristics of OGTT and Correlation Between the Insulin to C-Peptide Molar Ratio, HOMA-IR, and Insulin Antibodies in T2DM Patients. Diabetes Metab Syndr Obes 2022; 15:2417-2425. [PMID: 35971523 PMCID: PMC9375563 DOI: 10.2147/dmso.s373475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE The purpose of our study was to analyze the characteristics of OGTT and the correlation between the insulin to C-peptide molar ratio (ICPR), HOMA-IR and insulin antibodies (IAs) in T2DM patients. PATIENTS AND METHODS A total of 77 T2DM patients were included and divided into the IA+ group (25 patients) and IA- group (52 patients). The values of serum glucose, insulin, and C-peptide testing during 2-h OGTT were summarized comparatively, and ROC was made to analyze the predictive value of ICPR for IAs. RESULTS At each time point of OGTT, there was no significant difference in serum glucose and C-peptide changes (p>0.05). Serum insulin levels in positive patients were elevated or not at different time points of the OGTT but ICPR was significantly different (P<0.05) in the two groups. Spearman correlation coefficient analysis showed that the presence of insulin antibodies was correlated with ICPR, but not with HOMA-IR, and ICPR-2h had a better prediction capacity (AUC=0.735, the optimal cutoff-point=0.11, Se=0.760, Sp=0.635). CONCLUSION T2DM patients with IAs showed no difference in serum glucose and serum C-peptide changes, but elevated or not insulin levels on the OGTTs, compared with negative patients. ICPR-2h can be a preliminary diagnostic index to timely predict IAs in T2DM patients.
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Affiliation(s)
- Kai-Fang Hua
- Department of Endocrinology, Xiang’ an Hospital of Xiamen University, Xiamen, Fujian, People’ s Republic of China
- School of Medicine, Xiamen University, Xiamen, Fujian, People’ s Republic of China
| | - Ming-You Zhang
- School of Medicine, Xiamen University, Xiamen, Fujian, People’ s Republic of China
| | - Yao Zhang
- School of Medicine, Xiamen University, Xiamen, Fujian, People’ s Republic of China
| | - Bing-Jie Ren
- School of Medicine, Xiamen University, Xiamen, Fujian, People’ s Republic of China
| | - Yan-Hui Wu
- Department of Endocrinology, Xiang’ an Hospital of Xiamen University, Xiamen, Fujian, People’ s Republic of China
- Correspondence: Yan-Hui Wu, Department of Endocrinology, Xiang’ an Hospital of Xiamen University, 2000 Xiang’ an East Road, Xiamen, Fujian, 361102, People’ s Republic of China, Tel +86 13089998806, Email
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16
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Boro H, Gupta U, Singh C, Malhotra R, Khadgawat R. Continuous glucose monitoring and Rituximab treatment in insulin autoimmune syndrome. Diabetes Metab Syndr 2021; 15:102294. [PMID: 34562871 DOI: 10.1016/j.dsx.2021.102294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Insulin autoimmune syndrome (IAS) or Hirata's disease is a rare cause of hypoglycemia. It is characterized by hyperinsulinemic hypoglycemia, elevated insulin autoantibody titers, no prior exposure to exogenous insulin and no pathological abnormalities of pancreatic islets. Hypoglycemia usually occurs in the post prandial and post absorptive state. Most cases of IAS are self-limiting, with resolution of symptoms within six months to one year. In intractable cases, treatment modalities include low-carbohydrate meals; acarbose; diazoxide; glucocorticoids; immune-suppressants like Azathioprine, cyclophosphamide, mycophenolate mofetil; plasmapheresis and partial pancreatectomy. Rituximab, an anti CD20 monoclonal antibody, was first used in 2016 in a patient with IAS who did not respond to glucocorticoids. Subsequently, there have been three more case reports of IAS where Rituximab was used along with other modalities of treatment. Here, we report the case of a 64-year old Asian Indian woman who presented with recurrent episodes of severe post prandial hypoglycemia and was diagnosed with insulin autoimmune syndrome. She was managed with continuous glucose monitoring and two doses of Rituximab 10 weeks apart, that resulted in resolution of hypoglycemia. This case report underlies the role of Rituximab as a first line agent for treatment of hypoglycemia in IAS.
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Affiliation(s)
- Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Uttio Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Charandeep Singh
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rakhi Malhotra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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17
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Sutkowska E, Ostrowska M, Sutkowska M. Insulin Autoimmune Syndrome as Part of Pre-Clinical LADA. Diabetes Metab Syndr Obes 2021; 14:1557-1561. [PMID: 33859486 PMCID: PMC8043793 DOI: 10.2147/dmso.s302874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/04/2021] [Indexed: 12/12/2022] Open
Abstract
Hypoglycemia presents relatively typical symptoms. However, when it occurs spontaneously - like in insulin autoimmune syndrome - it is difficult to perform scheduled biochemical tests at the laboratory. The study presents the case of a 31-year-old Caucasian female whose recurrent hypoglycemia symptoms were the reason for further diagnostics. The final results revealed a positive test for insulin autoantibody and glutamic acid decarboxylase autoantibody. Therefore, not only the potential causes of hypoglycemia but also an active autoimmune process typical for latent autoimmune diabetes in adults were confirmed. It was concluded that autoimmune hypoglycemia can be a part of the autoimmune process associated with diabetes and pre-diabetes in adults.
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Affiliation(s)
- Edyta Sutkowska
- Medical Division, Department and Division of Medical Rehabilitation, Wroclaw Medical University, Wroclaw, Poland
- Correspondence: Edyta Sutkowska Department and Division of Medical Rehabilitation, Wroclaw Medical University, Borowska 213, Wroclaw, 50-556, PolandTel +48 71 734 32 20 Email
| | - Malgorzata Ostrowska
- Clinical Department of Nephrology and Dialysis Station, Karol Marcinkowski University Hospital, Zielona Gora, Poland
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18
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Yoshino H, Kawakami K, Kohriyama K, Yoshino G, Matsunaga S, Takechi H. Long-term follow-up of insulin autoimmune syndrome in an elderly patient. Clin Case Rep 2020; 8:2941-2944. [PMID: 33363855 PMCID: PMC7752643 DOI: 10.1002/ccr3.3150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 06/19/2020] [Accepted: 06/26/2020] [Indexed: 11/13/2022] Open
Abstract
An 84-year-old man was admitted to our hospital. His blood glucose level was 20 mg/dL. Since laboratory tests showed high titers of insulin antibodies, insulin autoimmune syndrome (IAS) was diagnosed. In order to avoid hypoglycemia, steroids can be effective in the long-term management of IAS in elderly patients.
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Affiliation(s)
- Hiroshi Yoshino
- Department of Geriatrics and Cognitive DisordersFujita Health University School of MedicineToyoakeJapan
- Center for DiabetesShin‐suma General HospitalKobeJapan
| | | | - Kenji Kohriyama
- Department of Internal MedicineShin‐suma General HospitalKobeJapan
| | - Gen Yoshino
- Center for DiabetesShin‐suma General HospitalKobeJapan
| | - Shinji Matsunaga
- Department of Geriatrics and Cognitive DisordersFujita Health University School of MedicineToyoakeJapan
| | - Hajime Takechi
- Department of Geriatrics and Cognitive DisordersFujita Health University School of MedicineToyoakeJapan
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19
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Boro H, Gupta U, Singh C, Malhotra R, Khadgawat R. Insulin Autoimmune Syndrome - A Case Series. EUROPEAN ENDOCRINOLOGY 2020; 16:168-171. [PMID: 33117451 DOI: 10.17925/ee.2020.16.2.168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/27/2020] [Indexed: 11/24/2022]
Abstract
Insulin autoimmune syndrome, or Hirata's disease, is a rare cause of hypoglycaemia. It is characterised by spontaneous episodes of hypoglycaemia, without any exposure to exogenous insulin. The majority of cases are seen in the Japanese population and it is rarely found to affect other ethnicities. The recognition of this disease is important to avoid unnecessary investigations and procedures. Here, we report two cases of insulin autoimmune syndrome, which were diagnosed and managed in our institute.
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Affiliation(s)
- Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Uttio Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Charandeep Singh
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rakhi Malhotra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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20
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Cimmino I, Faggiano A, Perruolo G, Modica R, Bottiglieri F, Covelli B, Colao A, Beguinot F, Formisano P, Oriente F. Diagnosis of Flier's syndrome in a patient with nondiabetic hypoglycemia: a case report and critical appraisal of the literature. Endocrine 2020; 69:73-78. [PMID: 32274699 DOI: 10.1007/s12020-020-02287-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Autoimmune hypoglycemia includes rare syndromes characterized by the presence of either anti-insulin antibodies (IAA) (Hirata's disease) or anti-insulin receptor (anti-ISR) antibodies (Flier's syndrome). Diagnosis is usually based on identification of the specific antibodies, in presence of the Whipple triad. However, most of these cases are classified as idiopathic diseases due to the difficulty to define the pathogenic culprit. METHODS Basic research methodologies, including Western Blot and ELISA tests, have been used in this study. RESULTS We describe a 21-year-old young woman (PT), non-obese and non-diabetic, with a positive history of autoimmune diseases, admitted to the hospital for recurrent episodes of severe symptomatic hypoglycemia. Counterregulatory response to hypoglycemia was normal as well as the fasting test, so excluding both hormone deficiencies and insulinoma. Since an autoimmune hypoglycemic syndrome was suspected, the hyperactivation of the insulin pathway was experimentally evaluated. At this purpose, human hepatocarcinoma (HepG2) cells were incubated with serum obtained from the patient (PT) and from control individuals. Interestingly, a significant increase of phosphorylation of insulin receptor, Akt, and ERK1/2 was observed in the HepG2 cells incubated with PT serum compared with the controls. ELISA tests revealed significantly increased levels of anti-ISR antibodies in PT serum, while IAA were similar both in PT and in control sera, supporting diagnosis of Flier's syndrome. CONCLUSIONS This study emphasizes the importance to identify new strategies for the differential diagnosis of hypoglycemia, not always possible with the routinely used diagnostic tests.
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Affiliation(s)
- Ilaria Cimmino
- Department of Translational Medicine, Federico II University of Naples and URT "Genomic of Diabetes" of Institute of Experimental Endocrinology and Oncology, National Council of Research (CNR), Naples, Italy
| | | | - Giuseppe Perruolo
- Department of Translational Medicine, Federico II University of Naples and URT "Genomic of Diabetes" of Institute of Experimental Endocrinology and Oncology, National Council of Research (CNR), Naples, Italy
| | - Roberta Modica
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Filomena Bottiglieri
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Bianca Covelli
- Department of Translational Medicine, Federico II University of Naples and URT "Genomic of Diabetes" of Institute of Experimental Endocrinology and Oncology, National Council of Research (CNR), Naples, Italy
| | - Annamaria Colao
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Francesco Beguinot
- Department of Translational Medicine, Federico II University of Naples and URT "Genomic of Diabetes" of Institute of Experimental Endocrinology and Oncology, National Council of Research (CNR), Naples, Italy
| | - Pietro Formisano
- Department of Translational Medicine, Federico II University of Naples and URT "Genomic of Diabetes" of Institute of Experimental Endocrinology and Oncology, National Council of Research (CNR), Naples, Italy.
| | - Francesco Oriente
- Department of Translational Medicine, Federico II University of Naples and URT "Genomic of Diabetes" of Institute of Experimental Endocrinology and Oncology, National Council of Research (CNR), Naples, Italy
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Yukina M, Nuralieva N, Solovyev M, Troshina E, Vasilyev E. Insulin autoimmune syndrome. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190159. [PMID: 32554828 PMCID: PMC7354712 DOI: 10.1530/edm-19-0159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022] Open
Abstract
SUMMARY Insulin autoimmune syndrome (Hirata's disease) is a disorder caused by development of autoantibodies to insulin and manifested by hypoglycaemic syndrome. The overwhelming majority of physicians do not include it in the differential diagnosis of hypoglycaemic states because of a misconception of an extremely low prevalence of this condition. This results in unnecessary drug therapy and unjustified surgical interventions in patients that otherwise would be successfully treated conservatively. This disease is strongly associated with certain alleles of the HLA gene. In most cases, this condition develops in predisposed individuals taking drugs containing sulfhydryl groups. Formation of autoantibodies to insulin may be observed in patients with other autoimmune disorders, as well as in those with multiple myeloma or monoclonal gammopathy of undetermined significance. This paper presents the first Russian case report of insulin autoimmune syndrome in an adult patient. LEARNING POINTS Insulin autoimmune syndrome, Hirata's disease, anti-insulin antibodies, and hypoglycaemia.
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Affiliation(s)
- Marina Yukina
- Department of Therapeutic Endocrinology, Endocrinology Research Centre (ERC), Moscow, Russia
| | - Nurana Nuralieva
- Department of Therapeutic Endocrinology, Endocrinology Research Centre (ERC), Moscow, Russia
| | - Maksim Solovyev
- Department of Therapeutic Endocrinology, Endocrinology Research Centre (ERC), Moscow, Russia
| | - Ekaterina Troshina
- Department of Therapeutic Endocrinology, Endocrinology Research Centre (ERC), Moscow, Russia
- Russian Academy of Sciences, Endocrinology Service, Department of Therapeutic Endocrinology, Endocrinology Research Centre (ERC), Moscow, Russia
| | - Evgeny Vasilyev
- Laboratory of Inherited Endocrine Disorders, Endocrinology Research Centre (ERC), Moscow, Russia
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Bottinelli C, Cartiser N, Bévalot F, Fanton L, Guitton J. Is insulin intoxication still the perfect crime? Analysis and interpretation of postmortem insulin: review and perspectives in forensic toxicology. Crit Rev Toxicol 2020; 50:324-347. [PMID: 32458714 DOI: 10.1080/10408444.2020.1762540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Insulin is an anabolic hormone essential to glucose homeostasis. Insulin therapy, comprising human insulin (HI) or biosynthetic analogs, is critical for the management of type-1 diabetes and many of type-2 diabetes. However, medication error including non-adapted dose and confusion of insulin type, and misuse, such as massive self-administration or with criminal intent, can have lethal consequences. The aim of this paper is to review the state of knowledge of insulin analysis in biological samples and of the interpretation of insulin concentrations in the situation of insulin-related death investigations. Analytic aspects are considered, as quantification can be strongly impacted by methodology. Immunoanalysis, the historical technique, has a prominent role due to its sensitivity and ease of implementation. Recently, liquid chromatography coupled to mass spectrometry has provided indispensable selectivity in forensic contexts, distinguishing HI, analogs, and degradation products. We review the numerous antemortem (dose, associated pathology, injection-to-death interval, etc.) and postmortem parameters (in corpore degradation, in vitro degradation related to hemolysis, etc.) involved in the interpretation of insulin concentration. The interest and limitations of various alternative matrices providing a valuable complement to blood analysis are discussed. Vitreous humor is one of the most interesting, but the low diffusion of insulin in this matrix entails very low concentrations. Injection site analysis is relevant for identifying which type of insulin was administered. Muscle and renal cortex are matrices of particular interest, although additional studies are required. A table containing most case reports of fatal insulin poisoning published, with analytical data, completes this review. A logic diagram is proposed to highlight analytical issues and the main parameters to be considered for the interpretation of blood concentrations. Finally, it remains a challenge to provide reliable biological data and solid interpretation in the context of death related to insulin overdose. However, the progress of analytical tools is making the "perfect crime" ever more difficult to commit.
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Affiliation(s)
| | - Nathalie Cartiser
- Département de médecine légale, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Laurent Fanton
- Département de médecine légale, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France.,Faculté de médecine Lyon Est, Institut de Médecine Légale, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Guitton
- Laboratoire de Toxicologie, ISPB-Faculté de Pharmacie, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.,Hospices Civils de Lyon, Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Lyon-Sud, Pierre Bénite Cedex, France
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Patel M, Shah R, Ramteke-Jadhav S, Patil V, Patel SK, Lila A, Shah N, Bandgar T. Management of Insulin Autoimmune Hypoglycaemia: Single-centre experience from Western India with systematic review of world literature. Clin Endocrinol (Oxf) 2020; 92:409-420. [PMID: 32064669 DOI: 10.1111/cen.14174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Awareness about Insulin Autoimmune Hypoglycaemia (IAH) and its management remains limited. METHODOLOGY We describe two cohorts: Cohort 1 (n = 7) included patients with IAH from a tertiary care centre in India and Cohort 2 (n = 294) included systematic review of published English literature from PubMed. They were compared with our insulinoma patients (n = 41). RESULTS Cohort 1 included seven female patients where two had drugs (carbimazole and thiocolchicoside) as triggering factors. Except for one patient requiring oral prednisolone, others had spontaneous remission. The unique features from our series are being first case series of IAH from India and reporting of second case of thiocolchicoside triggered IAH. Cohort 2 had 294 patients identified from 149 publications. Mean age was 54 ± 19 years. Thirty-five different triggers were identified from 160 cases. Antithyroid drugs were most common triggers in Japanese patients and most common HLA allele was DRB1*0406, while it was alpha-lipoic acid and HLA DRB1*0403 in non-Asians. Serum Insulin >100 µIU/mL and insulin to C-peptide molar ratio (ICMR) >0.25 had specificity of 100% and 97.5%, respectively, for IAH as compared to insulinoma. 56% patients had remission with complex carbohydrate diet and trigger removal while 43% required immunosuppressants. 70% achieved remission within 6 months. CONCLUSIONS Middle age remains most common age group. Sulfhydryl drugs are most common triggers. Serum Insulin >100 µIU/mL and ICMR > 0.25 in critical sample are good predictors for diagnosis of IAH, which needs to be confirmed by IAA. Conservative management with dietary modification and trigger removal usually suffices in majority. Rests need immunosuppressants.
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Affiliation(s)
- Muniraj Patel
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
| | - Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
| | - Swati Ramteke-Jadhav
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
| | | | - Anurag Lila
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, India
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Cappellani D, Macchia E, Falorni A, Marchetti P. Insulin Autoimmune Syndrome (Hirata Disease): A Comprehensive Review Fifty Years After Its First Description. Diabetes Metab Syndr Obes 2020; 13:963-978. [PMID: 32308449 PMCID: PMC7136665 DOI: 10.2147/dmso.s219438] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/13/2020] [Indexed: 01/10/2023] Open
Abstract
Insulin autoimmune syndrome (IAS), also named Hirata's disease, is a rare condition characterized by hypoglycemic episodes due to the presence of high titers of insulin autoantibodies (IAA). IAS is a form of immune-mediated hypoglycemia, which develops when a triggering factor (ie, a medication or a viral infection) acts on an underlying predisposing genetic background. IAS pathogenesis involves the formation of insulin-IAA complexes that induce glycemic alterations with a double-phase mechanism: IAA prevent insulin to bind its receptor in the postprandial phase, possibly resulting in mild hyperglycemia; thereafter, insulin is released from the complexes irrespective of blood glucose concentrations, thus inducing hypoglycemia. The diagnosis of IAS is challenging, requiring a careful workup aimed at excluding other causes of hyperinsulinemic hypoglycemia. The gold standard for the definitive diagnosis is the finding of IAA in a blood sample. Because IAS is frequently a self-remitting disease, its management mostly consists of supportive measures, such as dietary modifications, aimed at preventing the development of hypoglycemia. Pharmacological therapies may occasionally be necessary for patients presenting with severe manifestations of IAS. Available therapies may include drugs that reduce pancreatic insulin secretion (somatostatin analogues and diazoxide, for instance) and immunosuppressive agents (glucocorticoids, azathioprine and rituximab). The purpose of this review is to provide a comprehensive analysis of the disease, by describing the burden of knowledge that has been obtained in the 50 years following its first description, took in 1970, and by highlighting the points that are still unclear in its pathogenesis and management.
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Affiliation(s)
- Daniele Cappellani
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
- Correspondence: Daniele Cappellani Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, Pisa56124, ItalyTel +39 50 995001Fax +39 50 578772 Email
| | - Enrico Macchia
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Alberto Falorni
- Department of Medicine, Section of Internal Medicine and Endocrine and Metabolic Sciences, University of Perugia, Perugia, Italy
| | - Piero Marchetti
- Department of Clinical and Experimental Medicine, Division of Metabolism and Cell Transplantation, University of Pisa, Pisa, Italy
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Shen Y, Song X, Ren Y. Insulin autoimmune syndrome induced by exogenous insulin injection: a four-case series. BMC Endocr Disord 2019; 19:148. [PMID: 31883520 PMCID: PMC6935495 DOI: 10.1186/s12902-019-0482-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia and is characterized by the presence of insulin autoantibodies. Patients with IAS usually complain of hypoglycemia without any previous insulin received. Glucocorticoids and immunosuppressants are used to treat IAS. CASE PRESENTATION We report four patients with diabetes who were diagnosed with non-classical IAS and describe the treatment of these patients. Moreover, the differential diagnosis with hyperinsulinism is discussed. CONCLUSION High levels of insulin autoantibodies, as well as hyperinsulinemic hypoglycemia, are found in patients with diabetes mellitus and prior exogenous insulin exposure. This situation that we classified as non-classical IAS should be attached importance to.
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Affiliation(s)
- Yimin Shen
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
- Zhejiang University School of Medicine, Zhejiang, 310058 China
| | - Xiaoxiao Song
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
| | - Yuezhong Ren
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
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Insulin Autoimmune Syndrome in a 25-Year-Old, Previously Healthy Kuwaiti Man. Case Rep Endocrinol 2019; 2019:8919457. [PMID: 31915554 PMCID: PMC6930746 DOI: 10.1155/2019/8919457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
Abstract
Insulin autoimmune syndrome (IAS) is a disease characterized by hyperinsulinaemic hypoglycaemia associated with autoantibodies against endogenous insulin. We have described a case of a 25-year-old, previously healthy Kuwaiti man who was admitted to the Mubarak Al-Kabeer hospital with a history of recurrent hypoglycaemia. The patient revealed that he had taken several different injectable anabolic steroids and growth hormone with oral amino acids and other tablets (fat burners) for bodybuilding in the last two months. He denied knowingly using insulin or insulin analogues. The patient had elevated fasting insulin level (>301 uIU/mL) and elevated insulin autoantibodies (>100.0 IU/mL). After appropriate work-up, he was diagnosed with IAS. After treatment with prednisolone (1 mg/kg/day), the patient had complete recovery. In patients with repeated hypoglycaemia, IAS should be considered in the differential diagnosis. Glucocorticoid therapy can be effective for the treatment of hypoglycaemia in patients with IAS.
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Shin Y, Oh TJ, Choi SH, Jang HC. Insulin autoimmune syndrome in patients with type 2 diabetes: A report of two cases. DIABETES & METABOLISM 2019; 47:101115. [PMID: 31445080 DOI: 10.1016/j.diabet.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Y Shin
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South-Korea
| | - T J Oh
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South-Korea.
| | - S H Choi
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South-Korea
| | - H C Jang
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South-Korea
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Yuan T, Li J, Li M, Li N, Duan L, Ping F, Li W, Wang L, Zhao W. Insulin Autoimmune Syndrome Diagnosis and Therapy in a Single Chinese Center. Clin Ther 2019; 41:920-928. [PMID: 30992145 DOI: 10.1016/j.clinthera.2019.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 09/28/2018] [Accepted: 03/16/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE Insulin autoimmune syndrome (IAS) is a relatively rare cause of hypoglycemia characterized by endogenous hyperinsulinism and autoantibodies against endogenous insulin despite no prior exposure to exogenous insulin. We present a series of IAS cases and describe the clinical characteristics of these cases. METHODS The medical records of inpatients with the final diagnosis of IAS were collected from August 2007 to August 2017 in Peking Union Medical College Hospital. Clinical characteristics and laboratory test results were summarized. The results of serum glucose, insulin, true insulin, and C-peptide testing during 5-h oral glucose tolerance tests were also summarized. Circulating immune complexes were assessed qualitatively by precipitation with polyethylene glycol (PEG) in some patients. FINDINGS Sixteen patients were included in this study. Insulin autoimmune antibody test results were found positive in 12 patients and weakly positive in 1 patient. Nine patients had an insulin to C-peptide molar ratio >1, whereas 6 patients had an insulin to C-peptide molar ratio <1. Circulating immune complexes were verified in all 4 patients who had been assessed with PEG. During 5-h oral glucose tolerance tests, the C-peptide level responded earlier to the glucose tolerance and had a shorter peak value period compared with insulin, although C-peptide's fluctuation still lagged behind the glucose fluctuation. Three patients presented with self-limited disease courses or limited disease course after discontinuing use of the sulfhydryl group drugs. Some patients' symptoms were relieved after small frequent meals, and some were relieved after taking acarbose. Only 3 patients took glucocorticoids as the anti-immune therapy. IMPLICATIONS The insulin to C-peptide molar ratios were not consistently >1 in patients with confirmed diagnoses of IAS in our study, which suggested the low sensitivity of insulin to C-peptide molar ratio to detect IAS. The therapy in our study also revealed the self-limited disease course of IAS, and despite the effectiveness of anti-immunity therapy, convenient therapy, such as frequent small meals and adding acarbose, performed well in many patients.
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Affiliation(s)
- Tao Yuan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jiapei Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Naishi Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lian Duan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Linjie Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Weigang Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
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Guilmette J, Nosé V. Paraneoplastic syndromes and other systemic disorders associated with neuroendocrine neoplasms. Semin Diagn Pathol 2019; 36:229-239. [PMID: 30910348 DOI: 10.1053/j.semdp.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Neuroendocrine paraneoplastic syndromes (PNS) consist of metabolic disorders that accompany benign and malignant neoplasms but remain unrelated to mass effects or invasion by the primary tumor or its metastases. The underlying pathogenesis responsible for PNS usual clinical presentation relies on aberrant production of protein hormones, proteins and other substances by the tumor. Prompt recognition of characteristic signs and symptoms combined with serological identification of key substances may result in early diagnosis of PNS and its underlying malignancy. For these reasons, healthcare professionals should familiarize themselves with tumor-induced hypercalcemia, syndrome of inappropriate antidiuretic hormone, carcinoid syndrome, virilisation syndrome, gynecomastia, acromegaly, Cushing syndrome, osteogenic osteomalacia, tumor-induced hypoglycemia, necrolytic migratory erythema, and watery diarrhea, hypokalemia and achlorydria syndrome. Medical awareness for PNS can improve patient outcomes through earlier administration of cancer therapy and treatment, better symptomatic relief and prolong overall survival.
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Affiliation(s)
- Julie Guilmette
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, United States; Department of Pathology, Charles-Lemoyne Hospital, Greenfield Park, Quebec, Canada
| | - Vânia Nosé
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, United States.
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Veltroni A, Zambon G, Cingarlini S, Davì MV. Autoimmune hypoglycaemia caused by alpha-lipoic acid: a rare condition in Caucasian patients. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180011. [PMID: 30532998 PMCID: PMC6300856 DOI: 10.1530/edm-18-0011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 11/22/2018] [Indexed: 11/08/2022] Open
Abstract
Insulin autoimmune syndrome (IAS), a rare cause of autoimmune hyperinsulinaemic hypoglycaemia, is relatively well known in Japan. The incidence in Caucasians is less than one-fifth of that reported in Japanese people, but it is becoming increasingly recognised worldwide in non-Asians as well. Drugs containing sulphydryl groups are known to be associated with the disease in genetically predisposed individuals. Moreover, several recent reports showed a direct association between the onset of IAS and the consumption of dietary supplements containing alpha-lipoic acid (LA). Insulinoma remains the most prevalent cause of hypersulinaemic hypoglycaemia in Caucasians. Consequently, primary investigation in these patients is generally focused on localisation of the pancreatic tumour, often with invasive procedures followed by surgery. We described a case of an Italian woman presenting to us with severe recurrent hypoglycaemia associated with high insulin and C-peptide levels and no evidence of pancreatic lesions at imaging diagnostic procedures. She had taken LA until 2 weeks before hospitalisation. After an evaluation of her drug history, an autoimmune form of hypoglycaemia was suspected and the titre of insulin autoantibodies was found to be markedly elevated. This allowed us to diagnose LA-related IAS, thus preventing any unnecessary surgery and avoiding invasive diagnostic interventions. Learning points: IAS is a rare cause of hyperinsulinaemic hypoglycaemia that typically affects Asian population, but it has been increasingly recognised in Caucasian patients. It should be considered among the differential diagnosis of hyperinsulinaemic hypoglycaemia to avoid unnecessary diagnostic investigations and surgery. It should be suspected in the presence of very high serum insulin levels (100-10 000 μU/mL) associated with high C-peptide levels. There is a strong association with administration of drugs containing sulphydryl groups included LA, a dietary supplement commonly used in Western countries to treat peripheral neuropathy.
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Affiliation(s)
- A Veltroni
- ENETS Center of Excellence, Department of Medicine, University of Verona, Verona, Italy
| | - G Zambon
- ENETS Center of Excellence, Department of Medicine, University of Verona, Verona, Italy
| | - S Cingarlini
- ENETS Center of Excellence, Department of Oncology, University of Verona, Verona, Italy
| | - M V Davì
- ENETS Center of Excellence, Department of Medicine, University of Verona, Verona, Italy
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Cappellani D, Sardella C, Campopiano MC, Falorni A, Marchetti P, Macchia E. Spontaneously remitting insulin autoimmune syndrome in a patient taking alpha-lipoic acid. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180122. [PMID: 30532997 PMCID: PMC6300855 DOI: 10.1530/edm-18-0122] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/22/2018] [Indexed: 11/08/2022] Open
Abstract
Insulin autoimmune syndrome (IAS), or Hirata disease, is a rare hypoglycaemic disorder caused by the presence of high titer of insulin autoantibodies (IAA) in patients without previous exposure to exogenous insulin. Even though its pathogenesis is not fully understood, striking evidences link IAS to previous exposure to sulphydryl-containing medications, like alpha-lipoic acid, a widely used nutritional supplement. Although challenging, a careful differential diagnosis from other causes of hyperinsulinaemic hypoglycaemia (such as insulinoma) is mandatory, since these conditions require different therapeutic approaches. In the present study, we report a 35-year-old woman originally from Sri Lanka who was referred to our University Hospital on suspicion of occult insulinoma. Her medical history was positive for endometriosis, treated with estroprogestins and alpha-lipoic acid. The latter supplement was begun 2 weeks before the first hypoglycaemic episode. Our tests confirmed the presence of hypoglycaemia associated with high insulin and C-peptide concentrations. When insulin concentrations were compared using different assays, the results were significantly different. Moreover, insulin values significantly decreased after precipitation with polyethylene glycol. An assay for IAA proved positive (530 U/mL). A genetic analysis revealed the presence of HLA-DRB1*04,15, an immunogenetic determinant associated with IAS. On the basis of clinical data we avoided a first-line approach with immunosuppressive treatments, and the patient was advised to modify her diet, with the introduction of frequent low-caloric meals. During follow-up evaluations, glucose levels (registered trough a flash glucose monitoring system) resulted progressively more stable. IAA titer progressively decreased, being undetectable by the fifteenth month, thus indicating the remission of the IAS. Learning points: Insulin autoimmune syndrome (IAS) is a rare cause of hyperinsulinaemic hypoglycaemia, whose prevalence is higher in East Asian populations due to the higher prevalence of specific immunogenetic determinants. Nevertheless, an increasing number of IAS cases is being reported worldwide, due to the wide diffusion of medications such as alpha-lipoic acid. Differential diagnosis of IAS from other causes of hyperinsulinemic hypoglycaemia is challenging. Even though many tests can be suggestive of IAS, the gold standard remains the detection of IAAs, despite that dedicated commercial kits are not widely available. The therapeutic approach to IAS is problematic. As a matter of fact IAS is often a self-remitting disease, but sometimes needs aggressive immunosuppression. The benefits and risks of any therapeutic choice should be carefully weighted and tailored on the single patient.
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Affiliation(s)
- D Cappellani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - C Sardella
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M C Campopiano
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Falorni
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy
| | - P Marchetti
- Division of Metabolism and Cell Transplantation, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Macchia
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Censi S, Mian C, Betterle C. Insulin autoimmune syndrome: from diagnosis to clinical management. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:335. [PMID: 30306074 DOI: 10.21037/atm.2018.07.32] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Autoimmune forms of hypoglycemia are a rare cause of low blood sugar levels among Caucasians, and often go misdiagnosed, exposing patients to lengthy series of pointless, potentially harmful and expensive tests. There are two types of autoimmune hypoglycemia. One is insulin autoimmune syndrome (IAS), which is characterized by hyperinsulinemic hypoglycemia, elevated insulin autoantibody (IAA) titers, no prior exposure to exogenous insulin, and no of pathological abnormalities of the pancreatic islets. This condition is also known as "Hirata's disease". The other is type B insulin resistance syndrome (TBIRS), a rare autoimmune disorder resulting in a broad array of abnormalities in glucose homeostasis-from hypoglycemia to extremely insulin-resistant hyperglycemia-caused by the presence of insulin receptor autoantibodies (IRAbs). This review focuses on these two syndromes, describing their epidemiology, possible genetic background, clinical presentation, pathophysiology, diagnosis and treatment.
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Affiliation(s)
- Simona Censi
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Caterina Mian
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Corrado Betterle
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
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Cha S, Lee SH, Kang SH, Hasan MN, Kim YJ, Cho S, Lee YK. Antibody-mediated oral delivery of therapeutic DNA for type 2 diabetes mellitus. Biomater Res 2018; 22:19. [PMID: 30065848 PMCID: PMC6062860 DOI: 10.1186/s40824-018-0129-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/27/2018] [Indexed: 12/02/2022] Open
Abstract
Background Diabetes mellitus (DM) is a chronic progressive metabolic disease that involves uncontrolled elevation of blood glucose levels. Among various therapeutic approaches, GLP-1 prevents type 2 diabetes mellitus (T2DM) patients from experiencing hyperglycemic episodes. However, the short half-life (< 5 min) and rapid clearance of GLP-1 often limits its therapeutic use. Here, we developed an oral GLP-1 gene delivery system to achieve an extended antidiabetic effect. Methods Human IgG1 (hIgG1)-Fc-Arg/pDNA complexes were prepared by an electrostatic complexation of the expression plasmid with various ratios of the positively modified Fc fragments of an antibody (hIgG1-Fc-Arg) having a targeting ability to FcRn receptor. The shape and size of the complexes were examined by atomic force and field emission electron microscope. The stability of the complexes was tested in simulated gastrointestinal pH and physiological serum condition. Cellular uptake, transport, and toxicity of the complexes were tested in the Caco-2 cells. Biodistribution and antidiabetic effect of the complexes were observed in either Balb/c mice or Lepdb/db mice. Results A 50/1 ratio of the hIgG1-Fc-Arg/pDNA produced a complex structure having approximately 40 ~ 60 nm size and also demonstrated protection of pDNA in the complex from the physiological pH and serum conditions. Cellular uptake and transport of the complex were demonstrated in Caco-2 cells having FcRn receptor expression and forming the monolayer-polarized structure. The cellular toxicity of both delivery vehicle and the complex revealed their minimal toxicity comparable with nontoxicity of a commercial transfection reagent. Biodistribution of the complex showed the detectable distribution of the complex in the most parts of gastrointestinal tract due to ubiquitous expression of the FcRn receptors. An in vivo type 2 diabetes treatment study of oral administration of hIgG1-Fc-9Arg/pGLP-1 complexes showed absorption and expression in GI tract of either Balb/c mice or Lepdb/db mice. Conclusion In this study, we developed an oral GLP-1 gene delivery system on the platform of cationic hIgG1-Fc-9Arg. Prolonged t1/2, less immunoactivity, and better bioactivities of hIgG-Fc-9Arg/pGLP-1 complexes appeared to be a promising approach to achieve potent treatment of type 2 diabetes treatment. Electronic supplementary material The online version of this article (10.1186/s40824-018-0129-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Seungbin Cha
- 1Department of Biomedical Chemistry, Konkuk University, Chungju, 27478 Republic of Korea
| | | | | | - Mohammad Nazmul Hasan
- 3Department of Chemical and Biological Engineering, Korea National University of Transportation, Chungju, 27469 Republic of Korea
| | - Young Jun Kim
- 1Department of Biomedical Chemistry, Konkuk University, Chungju, 27478 Republic of Korea
| | - Sungpil Cho
- 44D Biomaterials Center, Korea National University of Transportation, Jeungpyeong, 27909 Republic of Korea
| | - Yong-Kyu Lee
- KB-Biomed, Chungju, 27469 Republic of Korea.,3Department of Chemical and Biological Engineering, Korea National University of Transportation, Chungju, 27469 Republic of Korea.,44D Biomaterials Center, Korea National University of Transportation, Jeungpyeong, 27909 Republic of Korea
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Wexler DJ, Macias-Konstantopoulos W, Forcione DG, Xiong L, Cauley CE, Pierce KJ. Case 23-2018: A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia. N Engl J Med 2018; 379:376-385. [PMID: 30044928 DOI: 10.1056/nejmcpc1802828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Deborah J Wexler
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Wendy Macias-Konstantopoulos
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - David G Forcione
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Lillian Xiong
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Christy E Cauley
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
| | - Kirsten J Pierce
- From the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Massachusetts General Hospital, and the Departments of Medicine (D.J.W., D.G.F.), Emergency Medicine (W.M.-K.), Radiology (L.X.), Surgery (C.E.C.), and Pathology (K.J.P.), Harvard Medical School - both in Boston
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Zeng XX, Tang YL, Hu KX, Wang J, Zhu LY, Liu JY, Xu JI. Insulin autoimmune syndrome in a pregnant female: A rare case report. Medicine (Baltimore) 2017; 96:e9213. [PMID: 29390469 PMCID: PMC5758171 DOI: 10.1097/md.0000000000009213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Insulin autoimmune syndrome (IAS) is an uncommon disorder characterized by hyperinsulinemic hypoglycemia related to insulin-binding autoantibodies. To the best of our knowledge, we report the first case of a pregnant female with IAS. PATIENT CONCERNS The 26-year-old patient with Graves disease and 10 weeks pregnant developed IAS after approximately 6 months treatment with methimazole. The patient exhibited recurrent spontaneous hypoglycemia. DIAGNOSES On evaluation, laboratory findings detected both high fasting insulin (>1000 mIU/L) and insulin autoantibodies. An oral glucose tolerance test showed elevated insulin concentrations with disproportionately elevated C-peptide levels. The imaging study showed nomasslesionsinthepancreas,and the patient was clinically diagnosed with IAS. INTERVENTIONS The patient had an abortion, discontinued methimazole and switched to oral prednisone (30 mg once daily) and propylth- iouracil (100 mg 3 times daily) for 3 months. OUTCOMES At the 3-month follow-up visit, hypoglycemic episodes had disappeared and insulin antibody levels were no longer detectable. LESSONS We have described this case and reviewed the relevant literature concerning diagnosis and treatment of IAS. Importantly, this case indicates that clinicians should view pregnancy as another factor of hypoglycemia in IAS.
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Manjunath PR, George B, Mathew V, Bantwal G, Ayyar V. "Riding High on Low Fuel" - Our Experience with Endogenous Hyperinsulinemic Hypoglycemia. Indian J Endocrinol Metab 2017; 21:655-659. [PMID: 28989869 PMCID: PMC5628531 DOI: 10.4103/ijem.ijem_174_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Endogenous hyperinsulinemic hypoglycemia (EHH) is a condition in which the insulin levels are inappropriately high in the presence of low plasma glucose. MATERIALS AND METHODS We did a retrospective analysis of case records of those patients admitted and evaluated for EHH from June 2004 to June 2016 in our center, excluding those that were diagnosed with reactive hypoglycemia. We collected data regarding demographics, clinical presentation, laboratory results, localization techniques, and treatment administered. RESULTS Sixteen patients who were admitted for evaluation based on history suggestive of repeated hypoglycemic episodes were included in the study. All but one pregnant patient was subjected to a supervised fast in the hospital. All patients developed hypoglycemia (defined using Whipple's triad) within the first 24 h. Three patients had autoimmune hypoglycemia which differed significantly from insulinoma-mediated hypoglycemia in certain clinical and laboratory parameters. They were older in age with marked fluctuations in the 24 h glucose profile ranging from frank hypoglycemia to frank hyperglycemia. The insulin levels were markedly elevated in this group of patients along with a significantly elevated insulin C peptide molar ratio (ICMR) when compared with patients with insulinoma-mediated hypoglycemia. CONCLUSIONS Although insulinoma is the most common cause of EHH, autoimmune hypoglycemia should be considered as a differential diagnosis, particularly in older individuals with plasma glucose values increasing to the hyperglycemic range. Degree of elevation of insulin levels and ICMR may provide additional clues. Overall, the survival and prognosis of patients with EHH are excellent.
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Affiliation(s)
- P. R. Manjunath
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Belinda George
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Vivek Mathew
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Ganapathi Bantwal
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
| | - Vageesh Ayyar
- Department of Endocrinology, St. John's Medical College, Bengaluru, Karnataka, India
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Ismail AAA. The insulin autoimmune syndrome (IAS) as a cause of hypoglycaemia: an update on the pathophysiology, biochemical investigations and diagnosis. Clin Chem Lab Med 2017; 54:1715-1724. [PMID: 27071154 DOI: 10.1515/cclm-2015-1255] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/23/2016] [Indexed: 12/11/2022]
Abstract
Insulin autoimmune syndrome (IAS) is considered to be very rare in Caucasians. Understanding its pathophysiology is paramount in (a) appreciating its potential impact on analyses of pancreatic hormones and (b) explaining its highly variable clinical manifestations in non-diabetic, non-acutely ill patients with indeterminate hypoglycaemia. The underlying aetiology of IAS is the presence of variable affinity/avidity endogenous insulin antibodies in significant amounts. The two types of insulin antibodies namely antibodies which bind insulin and/or proinsulin(s) and receptor antibodies (insulin mimetic) will be discussed. Their biochemical and immunological roles in causing hypoglycaemia will be highlighted. Clinical manifestations of IAS can vary from mild and transient to spontaneous, severe and protracted hypoglycaemia necessitating in extreme cases plasmapheresis for glycaemic control. Antibodies of IAS can interfere in pancreatic immunoassay tests causing erroneous and potentially misleading results. Thorough testing for endogenous insulin antibodies must be considered in the investigations of non-diabetic, non-acutely ill patients with indeterminate and/or unexplained hypoglycaemia.
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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Alam S, Ozair M, Ahmad J. Hypoglycemia due to Insulin Autoimmune Syndrome: A rare cause not to be forgotten. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2016. [DOI: 10.1016/j.jecr.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Narla RR, Hashimoto T, Kelly K, Heaney A. Hypoglycemia: A tale of three causes. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2016. [DOI: 10.1016/j.jecr.2016.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Chu JP, Zheng XW, Lu J, Zhong JY, Li JL, Xu M, Lin F. Insulin-induced autoimmune syndrome: A case report. Exp Ther Med 2016; 12:3359-3362. [PMID: 27882163 DOI: 10.3892/etm.2016.3767] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 08/25/2016] [Indexed: 12/12/2022] Open
Abstract
Insulin autoimmune syndrome (IAS) is a disease characterized by hyperinsulinemic hypoglycemia associated with autoantibodies against endogenous insulin. A 56-year-old man was admitted to Ningbo First Hospital for the treatment of spontaneous hypoglycemia. He was found to have elevated fasting insulin level (>1,000 mIU/l) and presence of insulin autoantibodies, and after appropriate workup, was diagnosed with IAS. After treating with prednisone for 2 months, his insulin level started decreasing. In patients with repeated hypoglycemia, IAS should be considered in the differential diagnosis. Prednisone may be effective for the treatment of hypoglycemia in patients with IAS.
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Affiliation(s)
- Jian-Ping Chu
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Xiao-Wei Zheng
- School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jie Lu
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jin-Yan Zhong
- School of Medicine, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Jia-Lin Li
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Miao Xu
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
| | - Fang Lin
- Department of Endocrinology, Ningbo First Hospital, Ningbo University, Ningbo, Zhejiang 315000, P.R. China
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Sahni P, Trivedi N, Omer A. Insulin Autoimmune Syndrome: a rare cause of postprandial hypoglycemia. Endocrinol Diabetes Metab Case Rep 2016; 2016:EDM160064. [PMID: 27855237 PMCID: PMC5093380 DOI: 10.1530/edm-16-0064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/15/2016] [Indexed: 11/08/2022] Open
Abstract
A 65-year-old obese Caucasian woman presented with symptomatic postprandial hypoglycemic episodes, resolution of symptoms with carbohydrate intake and significantly elevated anti-insulin antibody levels. She did not have any evidence for the use of oral antidiabetic medications, insulin, herbal substances, performing strenuous exercise or history of bariatric surgery. Fingerstick blood glucose readings revealed blood sugar of 35 mg/dL and 48 mg/dL, when she had these symptoms. Her medical history was significant for morbid obesity, hypothyroidism and gastro esophageal reflux disease. Her home medications included levothyroxine, propranolol and omeprazole. A blood sample obtained during the symptoms revealed the following: fingerstick blood sugar 38 mg/dL, venous blood glucose 60 mg/dL (normal (n): 70-99 mg/dL), serum insulin 202 IU/mL (n: <21), proinsulin 31.3 pmol/L (n: <28.9), C-peptide 8 ng/mL (n: 0.9-7), beta-hydroxybutyrate 0.12 mmol/L (n: 0.02-0.27) anti-insulin antibody >45.4 U/mL (n: <0.4). The result obtained while screening for serum sulfonylurea and meglitinides was negative. The repeated episodes of postprandial hypoglycemia associated with significantly elevated anti-insulin antibodies led to a diagnosis of insulin antibody syndrome (IAS). Significant improvement of hypoglycemic symptoms and lower anti-insulin antibody levels (33 U/mL) was noted on nutritional management during the following 6 months. Based on a report of pantoprazole-related IAS cases, her omeprazole was switched to a H2 receptor blocker. She reported only two episodes of hypoglycemia, and anti-insulin antibody levels were significantly lower at 10 U/mL after the following 12-month follow-up. LEARNING POINTS Initial assessment of the Whipple criteria is critical to establish the clinical diagnosis of hypoglycemia accurately.Blood sugar monitoring with fingerstick blood glucose method can provide important information during hypoglycemia workup.Autoimmune hypoglycemia is a rare cause of hypoglycemia, which can be diagnosed on high index of clinical suspicion and systematic evaluation.
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Affiliation(s)
- Pooja Sahni
- Division on Endocrinology and Metabolic Medicine and Department of Internal Medicine , St Vincent Hospital, Worcester, Massachusetts , USA
| | - Nitin Trivedi
- Division on Endocrinology and Metabolic Medicine and Department of Internal Medicine , St Vincent Hospital, Worcester, Massachusetts , USA
| | - Abdulkadir Omer
- Division on Endocrinology and Metabolic Medicine and Department of Internal Medicine , St Vincent Hospital, Worcester, Massachusetts , USA
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Kandaswamy L, Raghavan R, Pappachan JM. Spontaneous hypoglycemia: diagnostic evaluation and management. Endocrine 2016; 53:47-57. [PMID: 26951054 DOI: 10.1007/s12020-016-0902-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
Spontaneous hypoglycemia is a puzzling clinical problem and an important reason for referral to endocrinologists. Several clinical conditions such as insulinomas, non-insulinoma pancreatogenous hypoglycemia syndrome, insulin autoimmune syndrome, postprandial hypoglycemia (reactive hypoglycemia), non-islet cell tumor hypoglycemia, primary adrenal insufficiency, hypopituitarism, and critical illness can be associated with spontaneous hypoglycemia. Rarely, in patients with mental health issues, factious hypoglycemia from extrinsic insulin use or ingestion of oral hypoglycemic agents can obfuscate the clinical picture for clinicians trying to identify an organic cause. In those presenting with Whipple's triad (symptoms ± signs of hypoglycemia, low plasma glucose, and resolution symptoms ± signs after hypoglycemia correction), a 72-h supervised fast test with measurement of plasma insulin, c-peptide, pro-insulin, and beta-hydroxybutyrate levels, coupled with plasma/urine sulphonylurea screen, forms the first step in diagnostic evaluation. A mixed meal test is preferable for those with predominantly postprandial symptoms. Additional non-invasive and/or invasive diagnostic evaluation is necessary if an organic hypoglycemic disorder is suspected. With the aid of a few brief clinical case scenarios, we discuss the diagnostic evaluation and management of spontaneous hypoglycemia through this comprehensive article.
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Affiliation(s)
- Leelavathy Kandaswamy
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Rajeev Raghavan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Joseph M Pappachan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK.
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Abstract
Islet autoantibodies are the main markers of pancreatic autoimmunity in type 1 diabetes (T1D). Islet autoantibodies recognize insulin (IAA), glutamic acid decarboxylase (GADA), protein phosphatase-like IA-2 (IA-2A), and ZnT8 (ZnT8A), all antigens that are found on secretory granules within pancreatic beta cells. Islet antibodies, measured by sensitive and specific liquid phase assays, are the key parameters of the autoimmune response monitored for diagnostics or prognostics in patients with T1D or for disease prediction in at-risk individuals before T1D onset. Islet autoantibodies have been the main tool used to explore the natural history of T1D; this review summarizes the current knowledge about the autoantigens and the phenotype of islets autoantibodies acquired in large prospective studies from birth in children at risk of developing T1D.
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Affiliation(s)
- Vito Lampasona
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy.
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy.
| | - Daniela Liberati
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy
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Lechner K, Aulinger B, Brand S, Waldmann E, Parhofer KG. Hydrothermally modified slow release corn starch: a potential new therapeutic option for treating hypoglycemia in autoimmune hypoglycemia (Hirata's disease). Eur J Clin Nutr 2015; 69:1369-70. [PMID: 26373963 DOI: 10.1038/ejcn.2015.151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/27/2015] [Accepted: 07/31/2015] [Indexed: 11/09/2022]
Abstract
We report the successful treatment of autoimmune hypoglycemia in an 82-year-old non-diabetic Caucasian male with hydrothermally modified slow release corn starch, a product which is used in other conditions associated with hypoglycemia, most typically glycogen storage disease type I. An 82-year-old-Caucasian male presented with recurrent spontaneous hypoglycemia as low as 30 mg/dl following in-patient treatment for community acquired pneumonia. During a fasting-test, symptomatic hypoglycemia occurred. Plasma concentrations of c-peptide and insulin were considerably elevated. Autoimmune hypoglycemia was confirmed by the presence of insulin autoantibodies. While dietary restriction alone did not result in sufficient glucose control in this patient with autoimmune hypoglycemia, treatment with hydrothermally modified slow release corn starch led to stable euglycemia. This easy, well tolerated and non-invasive treatment may constitute a new therapeutic option for hypoglycemia in patients with autoimmune hypoglycemia who do not achieve sufficient control of hypoglycemia by dietary restriction alone.
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Affiliation(s)
- K Lechner
- Department of Medicine II, Ludwig-Maximilians-Universität München, Munich, Germany
| | - B Aulinger
- Department of Medicine II, Ludwig-Maximilians-Universität München, Munich, Germany
| | - S Brand
- Department of Medicine II, Ludwig-Maximilians-Universität München, Munich, Germany
| | - E Waldmann
- Department of Medicine II, Ludwig-Maximilians-Universität München, Munich, Germany
| | - K G Parhofer
- Department of Medicine II, Ludwig-Maximilians-Universität München, Munich, Germany
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