Insulin autoimmune syndrome as a cause of spontaneous hypoglycemia in alcoholic cirrhosis

Rare association of insulin autoimmune syndrome with ankylosing spondylitis

Insulin autoimmune syndrome (IAS) is a rare cause of hyperinsulinemic hypoglycaemia, which is known to occur in association with the use of sulfhydryl-containing drugs and autoimmune disorders. We describe a patient with hitherto an unreported association of IAS with ankylosing spondylitis. We have also performed and described a simplified method of polyethylene glycol (PEG) precipitation of an insulin bound antibody in the serum.

Recurrent hypoglycemia from insulin autoimmune syndrome

Insulin autoimmune syndrome (IAS) is an uncommon cause of hyperinsulinemic hypoglycemia characterized by autoantibodies to endogenous insulin in individuals without previous exposure to exogenous insulin. IAS is the third leading cause of spontaneous hypoglycemia in Japan, and is increasingly being recognized worldwide in non-Asian populations. We report a case of IAS in a Caucasian woman with recurrent complaints of hypoglycemia, with laboratory findings of serum glucose 2.5 mmol/L (45 mg/dL), insulin 54,930 pmol/L (7,909 μIU/mL), connecting peptide (C-peptide) 4,104 pmol/L (12.4 ng/mL), and a corresponding insulin to C-peptide molar ratio of 13.4 during a spontaneous hypoglycemic event. Autoantibodies to insulin were markedly elevated at > 50 kU/L (> 50 U/mL). IAS should be considered in the differential diagnosis of hypoglycemia in non-diabetic individuals. Distinction from insulinoma is especially crucial to prevent unwarranted invasive procedures and surgical interventions in hypoglycemic patients.

Diabetes mellitus and risk of hepatocellular carcinoma: findings from the Singapore Chinese Health Study

Background:

The increasing prevalence of diabetes may contribute to the rising incidence of hepatocellular carcinoma (HCC) in the US and other developed countries where HCC incidence is relatively low. Data from prospective studies on diabetes and risk of HCC in at-risk populations due to high prevalence of viral hepatitis in southeast Asia are sparse.

Methods:

The Singapore Chinese Health Study is a prospective cohort of 63 257 middle-aged and older Chinese men and women enrolled in 1993–1998. Besides an in-person interview administered to all participants at baseline, testing of serologic markers of hepatitis B or C infections were performed on a subset of cohort subjects. After a mean follow-up of 14 years, 499 cohort participants developed HCC.

Results:

A history of diabetes at baseline was associated with a hazard ratio of 2.14 (95% confidence interval, 1.69–2.71). This statistically significant association was comparable in magnitude between men and women, and remained equally strong across strata of subjects defined by the number of years between their first clinical diagnosis of diabetes and time of enrolment in this cohort. Within a nested case-control set of cohort subjects tested for serological markers of hepatitis B or C infections, the diabetes–HCC association was found to be present mainly among those devoid of any markers.

Conclusion:

A history of diabetes at baseline is highly associated with non-viral HCC. Future studies are warranted to elucidate the biological mechanism underpinning the role of diabetes in nonviral-related hepatocarcinogenesis.

Elevated alanine aminotransferase is associated with metabolic syndrome but not consistently associated with impaired fasting glucose or type 2 diabetes mellitus

BACKGROUND

Abnormally elevated alanine aminotransferase (ALT) of nonspecific causes is a common outpatient problem. Without considering ethnicity, several studies had suggested that it was associated with insulin resistance (IR).

OBJECTIVE

To investigate whether nonspecific elevated ALT in Taiwanese population could reflect a likely underlying IR and was associated with impaired fasting glucose or type 2 diabetes mellitus (IFG/T2DM).

METHODS

The health examination profiles of 1313 Taiwanese were investigated cross-sectionally. The prevalence and odds ratios (ORs) for IFG/T2DM and metabolic abnormalities in relation to elevated ALT were analyzed.

RESULTS

Subjects with metabolic syndrome (MS) all had IFG/T2DM. The elevated ALT significantly correlated with MS and IFG/T2DM (i.e., 19.9-29.2% vs. 7.8% for MS, and 27.0-31.5% vs. 16.1% for IFG/T2DM). However, after excluding MS and adjustment for age and sex, the elevated ALT alone was not consistently associated with IFG/T2DM (36 < ALT ≤ 80 IU/L with OR 0.97, 95% CI 0.58-1.61; 80 < ALT ≤ 120 IU/L with OR 0.55, 95% CI 0.13-2.37; none with ALT > 120 had IFG).

CONCLUSIONS

In a cross-sectional analysis of Taiwanese industrial employees, elevated ALT associated with MS, but in subjects who did not meet MS criteria, elevated ALT by itself did not associate with IFG/T2DM.

Role of continuous subcutaneous insulin infusion (insulin pump) in reducing blood glucose in four patients with type 2 diabetes and cirrhosis: a case series

BACKGROUND

Some people with type 2 diabetes mellitus (T2DM) and cirrhosis tend to have fluctuating glucose values usually uncontrolled with conventional therapy. The aim of this case series was to retrospectively analyze the effect of continuous subcutaneous insulin infusion (CSII) on four patients with cirrhosis and poorly controlled T2DM.

METHODS

The four patients in this case series presented with chronic cirrhosis with no ascitis, preexisting T2DM, and inadequate blood glucose (BG) control with conventional insulin therapy. After initiation of CSII, patients' BG values were monitored at regular intervals, and basal and bolus doses were adjusted. Fasting BG, postprandial BG, and glycated hemoglobin A1c (HbA1c) values were monitored while the patient was in the hospital, upon discharge, and at one follow-up visit.

RESULTS

The daily dose of insulin was reduced in three patients. Fasting and postprandial BG values returned to normal ranges for all four patients. HbA1c was reduced in all four patients and reduced to normal ranges in two patients. There were no recorded incidents of severe hypoglycemia, diabetic ketoacidosis, or weight gain associated with the use of CSII.

CONCLUSION

Initiation of CSII in patients with T2DM and cirrhosis was beneficial in controlling BG values in the four patients studied in this case series.

Autoimmune forms of hypoglycemia

Autoimmune syndromes are a rare cause of hypoglycemia characterized by elevated levels of insulin in the presence of either anti-insulin antibodies (insulin autoimmune syndrome) or anti-insulin receptor antibodies (type B insulin resistance). Insulin autoimmune syndrome is the third leading cause of hypoglycemia in Japan, but has rarely been described in the non-Asian population.In the current study, we report the clinical and biochemical characteristics and clinical course of 2 white patients with insulin autoimmune syndrome, and present a literature review of non-Asian patients reported with insulin autoimmune syndrome. Also, we describe the clinical and biochemical characteristics of patients reported in the literature with type B insulin resistance who manifested hypoglycemia. We compare the clinical and laboratory features of insulin autoimmune syndrome and type B insulin resistance with each other and with other forms of hyperinsulinemic hypoglycemia.Autoimmune forms of hypoglycemia are uncommon. However, they should be considered in any patient with hypoglycemia in the setting of unsuppressed insulin levels associated with anti-insulin or anti-insulin receptor antibodies. Making the correct diagnosis may spare a hypoglycemic patient from an unnecessary pancreatic surgical procedure.

Severe Autoimmune Hypoglycemia With Insulin Antibodies Necessitating Plasmapheresis

OBJECTIVE

To report a case of autoimmune hypoglycemia.

METHODS

We describe the clinical course of a patient with autoimmune hypoglycemia, including results of biochemical and histocompatibility antigen studies, as well as the therapeutic intervention and follow-up.

RESULTS

A 77-year-old man presented with clinical manifestations of severe spontaneous hypoglycemia associated with extremely high levels of insulin (>300 mU/mL) and insulin antibodies (>100 U/mL) without any exogenous insulin administration. He had no other associated autoimmune disorder or exposure to the sulfhydryl group of drugs. Corticosteroid therapy was initiated, but the patient continued to have hypoglycemia and required plasmapheresis. The hypoglycemia resolved after plasmapheresis. During follow-up, the patient was treated with prednisone, the dose of which was tapered gradually. The insulin antibodies, which had decreased rapidly after plasmapheresis, gradually disappeared within a few months. The patient remained free of hypoglycemia as well as insulin antibodies 11 months after corticosteroid therapy was discontinued.

CONCLUSION

Although autoimmune hypoglycemia is an uncommon disorder, it should be considered in any patient with hypoglycemia in the setting of nonsuppressed insulin levels associated with insulin antibodies.

Autoimmune hypoglycemia

Autoimmune hypoglycemia is a rare but fascinating syndrome of hypoglycemia caused by the interaction of endogenous antibodies with insulin or the insulin receptor. Awareness of autoimmune hypoglycemia is important because the syndrome may produce severe neuroglycopenic symptoms and may be confused with the presence of an insulinoma. A correct diagnosis is important to avoid unnecessary surgical intervention in patients who are best treated with conservative support, watchful waiting, or in some cases, immunosuppressive therapy.