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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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Abeyagunawardena I, Madurapperuma C, Thuvarakan P, Thowfeek Z, Sujeewa N, Katulanda G, Karunatilake H. Uncommon triggers of insulin autoimmune syndrome: a case report. J Med Case Rep 2024; 18:292. [PMID: 38926797 PMCID: PMC11210015 DOI: 10.1186/s13256-024-04616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Insulin autoantibody syndrome (IAS), or Hirata disease, is caused by high concentrations of insulin autoantibodies, which result in spontaneous, mainly post-prandial, hypoglycemic episodes. We report a case of a previously healthy 67-year-old man presenting with recurrent fasting hypoglycemia culminating in a diagnosis of insulin autoimmune syndrome linked to omeprazole and probably spices, namely, coriander, and ginger. CASE PRESENTATION A previously healthy 67-year-old Sinhalese man presented with recurrent syncopal attacks for 3 months, which were found to be hypoglycemic episodes. He experienced mainly fasting hypoglycemic attacks, at a frequency gradually increasing to daily attacks. His cardiovascular, respiratory, abdominal, and neurologic examinations were normal. He was found to have insulin levels > 6000 mU/L and a post-polyethylene glycol insulin recovery of less than 9.5%. Contrast-enhanced computed tomography of the pancreas was normal. The diagnosis of insulin autoantibody syndrome was confirmed by testing for the insulin autoantibody level, yielding a level of > 300 U/mL. With regard to a possible trigger, he had a history of omeprazole intake for 2 weeks, 4 weeks prior to the onset of symptoms. He also consumed an herbal supplement containing coriander and ginger extracts daily for a period of 1 year, approximately 2 years prior to the onset of hypoglycemic attacks. He was commenced on prednisolone 30 mg daily, and hypoglycemic episodes responded dramatically, and thus he was tapered off corticosteroids. CONCLUSION Omeprazole-induced insulin autoantibody syndrome is likely in this patient; however, the known hypoglycemic effects of coriander and ginger make it worthwhile to consider a possible association with insulin autoantibody syndrome. In addition, this case report highlights the need to consider insulin autoantibody syndrome even in patients presenting with fasting hypoglycemic attacks.
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3
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Clifford L, Joseph F, Joshi T. A clinical case of insulin autoimmune syndrome with monoclonal gammopathy of uncertain significance; complexity in management. Oxf Med Case Reports 2024; 2024:omae054. [PMID: 38860020 PMCID: PMC11162579 DOI: 10.1093/omcr/omae054] [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: 11/29/2023] [Revised: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 06/12/2024] Open
Abstract
Insulin autoimmune syndrome (IAS) is a rare cause of spontaneous hypoglycaemia. We discuss a 91-year-old Caucasian lady who presented with syncope and episodic adrenergic and neuroglycopenic symptoms. Despite significantly elevated insulin, C-peptide, and proinsulin levels with the presence of anti-insulin antibodies, a pancreatic mass was not identified. Serum immunoelectrophoresis demonstrated monoclonal gammopathy of undetermined significance (MGUS). Treatment involved high-dose steroids, diazoxide, corn starch and acarbose, however the patient passed away four months later due to worsening co-morbidities. The management of IAS in the setting of MGUS is challenging.
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Affiliation(s)
- Liam Clifford
- Department of Endocrinology, Gosford Hospital, Gosford, NSW, Australia
| | - Flavian Joseph
- Department of Endocrinology, Gosford Hospital, Gosford, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | - Tripti Joshi
- Department of Endocrinology, Gosford Hospital, Gosford, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
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Padarabinda Tripathy K, Pathi D, Kumar Behera P, Das S, Tarun Venkat Mahesh S. An Unusual Case of Hypoglycemia in a Non-diabetic Individual due to Hirata Disease. Cureus 2024; 16:e56297. [PMID: 38629013 PMCID: PMC11018556 DOI: 10.7759/cureus.56297] [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] [Accepted: 03/16/2024] [Indexed: 04/19/2024] Open
Abstract
Hypoglycemia is common in diabetic populations using insulin or insulin secretagogues, but rare in non-diabetics. A 60-year-old non-diabetic male presented with repeated episodes of abnormal behavior persisting for 10-15 minutes for seven days, associated with sweating, intense hunger, and relief on food intake, with no history of insulin or secretagogue intake, with stable vitals and normal systemic examination. Laboratory tests during attacks revealed low blood sugar, high serum insulin, and normal C-peptide levels, with no evidence of pancreatic or extrapancreatic hyperinsulinism, and serum anti-insulin antibody levels >100 U/ml. Based on these results, he was diagnosed with autoimmune insulin syndrome (AIS). Treatment with low-carb meals, oral prednisolone, and acarbose led to the resolution of symptoms. Hirata syndrome, though rare in India, requires consideration as a differential diagnosis to avoid unnecessary invasive procedures.
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Affiliation(s)
| | - Debasis Pathi
- General Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Sambit Das
- Endocrinology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Du W, Wang H, Liu Y, Hong T. Recurrent hypoglycemia induced by clopidogrel: A case report and mini review. J Diabetes Investig 2024; 15:275-281. [PMID: 38063248 PMCID: PMC10906020 DOI: 10.1111/jdi.14110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/26/2023] [Accepted: 11/04/2023] [Indexed: 03/02/2024] Open
Abstract
This report describes a patient who developed recurrent hypoglycemia episodes after 23 days of antiplatelet therapy with clopidogrel for left subclavian artery stent implantation. The patient suffered from palpitation, profuse sweating and weakness on the 23rd day of clopidogrel treatment. The minimum plasma glucose was 2.2 mmol/L, and the hypoglycemia was associated with significantly elevated levels of insulin. A diagnosis of insulin autoimmune syndrome (IAS) was made with the presence of insulin autoantibody and a comprehensive differential diagnosis of other conditions related with hypoglycemia. Clopidogrel was stopped, and the patient was treated with acarbose and had frequent low-carbohydrate meals; his hypoglycemia did not occur within 10 days. To date, seven cases of IAS induced by clopidogrel have been reported. Most reported cases were male aged in their 70s, and the hypoglycemic attack appeared 1-4 weeks after exposure to clopidogrel, characterized by severe hyperinsulinemia hypoglycemia with high titers of insulin autoantibodies. Most IAS cases can resolve spontaneously when they stop using the trigger medicine. Severe cases had been treated with drugs that reduce pancreatic insulin secretion (such as somatostatin and diazoxide), immunosuppressants (glucocorticoids, azathioprine and rituximab) and even immunoadsorption to remove the insulin autoantibody from the body. Considering the hypoglycemic attack might increase the risk of cardiovascular events among patients taking clopidogrel, we recommend that doctors should be aware of IAS as a rare severe adverse effect of clopidogrel, and be vigilant for the symptoms related with hypoglycemia in clopidogrel users.
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Affiliation(s)
- Weiguan Du
- Department of Endocrinology and metabolismPeking University Third HospitalBeijingChina
| | - Haining Wang
- Department of Endocrinology and metabolismPeking University Third HospitalBeijingChina
| | - Ye Liu
- Department of Endocrinology and metabolismPeking University Third HospitalBeijingChina
| | - Tianpei Hong
- Department of Endocrinology and metabolismPeking University Third HospitalBeijingChina
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Grant B, Ratnayake G, Williams CL, Long A, Halsall DJ, Semple RK, Cavenagh JD, Drake WM, Church DS. Resolution of dysglycaemia after treatment of monoclonal gammopathy of endocrine significance. Eur J Endocrinol 2023; 189:K25-K29. [PMID: 37818852 PMCID: PMC10711369 DOI: 10.1093/ejendo/lvad138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/14/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
In very rare cases of monoclonal gammopathy, insulin-binding paraprotein can cause disabling hypoglycaemia. We report a 67-year-old man re-evaluated for hyperinsulinaemic hypoglycaemia that persisted despite distal pancreatectomy. He had no medical history of diabetes mellitus or autoimmune disease but was being monitored for an IgG kappa monoclonal gammopathy of undetermined significance. On glucose tolerance testing, hyperglycaemia occurred at 60 min (glucose 216 mg/dL) and hypoglycaemia at 300 min (52 mg/dL) concurrent with an apparent plasma insulin concentration of 52 850 pmol/L on immunoassay. Laboratory investigation revealed an IgG2 kappa with very high binding capacity but low affinity (Kd 1.43 × 10-6 mol/L) for insulin. The monoclonal gammopathy was restaged as smouldering myeloma not warranting plasma cell-directed therapy from a haematological standpoint. Plasma exchange reduced paraprotein levels and improved fasting capillary glucose concentrations. Lenalidomide was used to treat disabling hypoglycaemia, successfully depleting paraprotein and leading to resolution of symptoms.
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Affiliation(s)
- Bonnie Grant
- Department of Endocrinology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - Gowri Ratnayake
- Department of Endocrinology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - Claire L Williams
- Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research, Southmead Hospital, Bristol BS10 5NB, United Kingdom
| | - Anna Long
- Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research, Southmead Hospital, Bristol BS10 5NB, United Kingdom
| | - David J Halsall
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Robert K Semple
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh EH4 2XU, United Kingdom
| | - James D Cavenagh
- Department of Haematolo-Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - William M Drake
- Department of Endocrinology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, United Kingdom
| | - David S Church
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
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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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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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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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Kawamura R, Miyao S, Onuma H, Uchigata Y, Kawasaki E, Ohashi J, Shiraishi S, Nishida W, Yokomoto-Umakoshi M, Takata Y, Osawa H, Makino H. Recurrent Hypoglycemia Due to a High Titer of Insulin Antibody in Response to Exogenous Insulin Administration in Two Cases of Type 1 Diabetes. Intern Med 2022; 61:687-695. [PMID: 34471020 PMCID: PMC8943391 DOI: 10.2169/internalmedicine.7647-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In the first case, a 60-year-old man who was using continuous subcutaneous insulin infusion (CSII), developed recurrent hypoglycemia due to insulin antibodies. This is the first report of such a case using CSII. In the second case, a 70-year-old man was follow-up case who developed hypoglycemia while using human insulin. In both cases, the hypoglycemia subsided after switching to multiple daily insulin injection and/or insulin preparation. The results of Scatchard analyses of the two cases were similar to those of cases of insulin autoimmune syndrome (IAS) that improved after recovery from hypoglycemia.The clinical characteristics and Scatchard analysis data were essentially the same as those for IAS, except for the presence of insulin administration.
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Affiliation(s)
- Ryoichi Kawamura
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | | | - Hiroshi Onuma
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
- Department of Diabetes, Endocrine and Metabolic Disease, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | | | - Eiji Kawasaki
- Department of Diabetes and Endocrinology, Shin-Koga Hospital, Japan
| | - Jun Ohashi
- Department of Biological Sciences, Graduate School of Science, The University of Tokyo, Japan
| | | | - Wataru Nishida
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Maki Yokomoto-Umakoshi
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Yasunori Takata
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
| | - Hideichi Makino
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Japan
- Shiraishi Hospital Diabetes Center, Japan
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Autoreactive antibodies control blood glucose by regulating insulin homeostasis. Proc Natl Acad Sci U S A 2022; 119:2115695119. [PMID: 35131852 PMCID: PMC8833180 DOI: 10.1073/pnas.2115695119] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 12/31/2022] Open
Abstract
The random nature of antibody repertoire generation includes the potential of producing autoantibodies recognizing self-structures. It is believed that establishing immunological tolerance and prevention of autoimmune diseases require the removal of antibody specificities recognizing self. Using insulin as a common and physiologically important autoantigen, we show that anti-insulin antibodies associated with autoimmune diabetes can readily be detected in mice and humans and are involved in the physiological regulation of blood glucose levels. Importantly, human high-affinity, anti-insulin IgM antibodies protect insulin from autoimmune degradation by anti-insulin IgG antibodies. Thus, in contrast to the proposed negative selection, self-recognition and the production of highly autoreactive IgM antibodies are important for tolerance induction. Homeostasis of metabolism by hormone production is crucial for maintaining physiological integrity, as disbalance can cause severe metabolic disorders such as diabetes mellitus. Here, we show that antibody-deficient mice and immunodeficiency patients have subphysiological blood glucose concentrations. Restoring blood glucose physiology required total IgG injections and insulin-specific IgG antibodies detected in total IgG preparations and in the serum of healthy individuals. In addition to the insulin-neutralizing anti-insulin IgG, we identified two fractions of anti-insulin IgM in the serum of healthy individuals. These autoreactive IgM fractions differ in their affinity to insulin. Interestingly, the low-affinity IgM fraction (anti-insulin IgMlow) neutralizes insulin and leads to increased blood glucose, whereas the high-affinity IgM fraction (anti-insulin IgMhigh) protects insulin from neutralization by anti-insulin IgG, thereby preventing blood glucose dysregulation. To demonstrate that anti-insulin IgMhigh acts as a protector of insulin and counteracts insulin neutralization by anti-insulin IgG, we expressed the variable regions of a high-affinity anti-insulin antibody as IgG and IgM. Remarkably, the recombinant anti-insulin IgMhigh normalized insulin function and prevented IgG-mediated insulin neutralization. These results suggest that autoreactive antibodies recognizing insulin are key regulators of blood glucose and metabolism, as they control the concentration of insulin in the blood. Moreover, our data suggest that preventing autoimmune damage and maintaining physiological homeostasis requires adaptive tolerance mechanisms generating high-affinity autoreactive IgM antibodies during memory responses.
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12
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Arora P, Prasad H, Ranjan N, Pillai A, Joseph N. An Unusual Case of Persistent Hypoglycemia in Scrub Typhus. Cureus 2022; 14:e21098. [PMID: 35165557 PMCID: PMC8829456 DOI: 10.7759/cureus.21098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
Acute fever is a common worldwide issue among patients presenting to the emergency department. Main tropical fevers presenting as acute fever are malaria, dengue fever, typhoid, scrub typhus, and leptospirosis. Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi, which is endemic in many parts of India. Its clinical presentation varies significantly from undifferentiated fever and fever with thrombocytopenia to meningoencephalitis. Persistent hypoglycemia in scrub typhus has not yet been reported. Here we report a case of a 27-year-old male who presented with altered mental status after seven days of scrub typhus diagnosis. Diagnosis of hypoglycemia (random blood sugar of 37 mg/dL) was made at triage. Altered mental status responded to dextrose, but despite meals and treatment, hypoglycemia persisted. The cause for persistent hypoglycemia remained unexplained as most laboratory panels for hypoglycemia were either normal or did not fit into a particular cause.
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Amendt T, Jumaa H. Adaptive tolerance: Protection through self-recognition. Bioessays 2022; 44:e2100236. [PMID: 34984705 DOI: 10.1002/bies.202100236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/11/2021] [Accepted: 12/17/2021] [Indexed: 01/10/2023]
Abstract
The random nature of immunoglobulin gene segment rearrangement inevitably leads to the generation of self-reactive B cells. Avoidance of destructive autoimmune reactions is necessary in order to maintain physiological homeostasis. However, current central and peripheral tolerance concepts fail to explain the massive number of autoantibody-borne autoimmune diseases. Moreover, recent studies have shown that in physiological mouse models autoreactive B cells were neither clonally deleted nor kept in an anergic state, but were instead able to mount autoantibody responses. We propose that activation of autoreactive B cells is induced by polyvalent autoantigen complexes that can occur under physiological conditions. Repeated encounter of autoantigen complexes leads to the production of affinity-matured autoreactive IgM that protects its respective self-targets from degradation. We refer to this novel mechanism as adaptive tolerance. This article discusses the discovery of adaptive tolerance and the unexpected role of high affinity IgM autoantibodies.
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Affiliation(s)
- Timm Amendt
- Institute of Immunology, University Hospital Ulm, Ulm, Germany
| | - Hassan Jumaa
- Institute of Immunology, University Hospital Ulm, Ulm, Germany
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Petersen MC, Graves JM, Yao T, Schomburg L, Minich WB, Parks DL, McGill JB, Salam M. Insulin Receptor Autoantibody-mediated Hypoglycemia in a Woman With Mixed Connective Tissue Disease. J Endocr Soc 2022; 6:bvab182. [PMID: 34913021 PMCID: PMC8668203 DOI: 10.1210/jendso/bvab182] [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: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
Autoantibodies to the insulin receptor are rare and typically cause severe insulin resistance and hyperglycemia, a condition termed type B insulin resistance. Uncommonly, antibodies to the insulin receptor can cause hypoglycemia. We present the case of a woman who developed recurrent severe hypoglycemia and myopathy, was found to have insulin receptor autoantibodies and mixed connective tissue disease, and had resolution of hypoglycemia with immunosuppression. A 55-year-old woman with a history of obesity, hypertension, and prior hemorrhagic stroke presented with recurrent severe hypoglycemia. A diagnostic fast resulted in hypoinsulinemic hypoketotic hypoglycemia. Adrenal function was intact. Progressive myopathy had developed simultaneously with her hypoglycemia, and rheumatologic evaluation revealed mixed connective tissue disease. The plasma acylcarnitine profile was normal, extensive oncologic evaluation including insulin-like growth factor 2 measurement was unrevealing, and anti-insulin antibody testing was negative. Ultimately, anti-insulin receptor antibodies were found to be present. The patient was treated with glucocorticoids and rituximab. Eight weeks after initiation of immunosuppression, the insulin receptor antibody titer had decreased and hypoglycemia had resolved. Eight months after diagnosis, the patient remained free of severe hypoglycemia despite tapering of glucocorticoids to a near-physiologic dose. Though antibodies to the insulin receptor typically cause severe insulin resistance, this patient had no evidence of insulin resistance and instead presented with recurrent severe hypoglycemia, which responded to glucocorticoids and rituximab. The diagnosis of insulin receptor antibody–mediated hypoglycemia is rare but should be considered in patients with systemic autoimmune disease, including mixed connective tissue disease, in the appropriate clinical context.
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Affiliation(s)
- Max C Petersen
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Jonah M Graves
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Tony Yao
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Waldemar B Minich
- Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Deborah L Parks
- Division of Rheumatology, Washington University School of Medicine, St Louis, MO 63110, USA
| | - Janet B McGill
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St Louis, Missouri 63110, USA
| | - Maamoun Salam
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St Louis, Missouri 63110, USA
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Amendt T, Jumaa H. Memory IgM protects endogenous insulin from autoimmune destruction. EMBO J 2021; 40:e107621. [PMID: 34369608 PMCID: PMC8408592 DOI: 10.15252/embj.2020107621] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022] Open
Abstract
The enormous diversity of antibody specificities is generated by random rearrangement of immunoglobulin gene segments and is important for general protection against pathogens. Since random rearrangement harbors the risk of producing self-destructive antibodies, it is assumed that autoreactive antibody specificities are removed during early B-cell development leading to a peripheral compartment devoid of autoreactivity. Here, we immunized wild-type mice with insulin as a common self-antigen and monitored diabetes symptoms as a measure for autoimmune disease. Our results show that autoreactive anti-insulin IgM and IgG antibodies associated with autoimmune diabetes can readily be generated in wild-type animals. Surprisingly, recall immunizations induced increased titers of high-affinity insulin-specific IgM, which prevented autoimmune diabetes. We refer to this phenomenon as adaptive tolerance, in which high-affinity memory IgM prevents autoimmune destruction by competing with self-destructive antibodies. Together, this study suggests that B-cell tolerance is not defined by the absolute elimination of autoreactive specificities, as harmful autoantibody responses can be generated in wild-type animals. In contrast, inducible generation of autoantigen-specific affinity-matured IgM acts as a protective mechanism preventing self-destruction.
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Affiliation(s)
- Timm Amendt
- Institute of ImmunologyUniversity Hospital UlmUlmGermany
| | - Hassan Jumaa
- Institute of ImmunologyUniversity Hospital UlmUlmGermany
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16
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Kay RG, Barker P, Burling K, Cohen M, Halsall D, Reimann F, Gribble FM, Semple RK, Church D. Increased C-Peptide Immunoreactivity in Insulin Autoimmune Syndrome (Hirata Disease) Due to High Molecular Weight Proinsulin. Clin Chem 2021; 67:854-862. [PMID: 34051096 PMCID: PMC8167340 DOI: 10.1093/clinchem/hvab043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/24/2021] [Indexed: 11/22/2022]
Abstract
Background Determination of C-peptide is important in the investigation of unexplained hyperinsulinemic hypoglycemia because a high C-peptide concentration usually indicates endogenous insulin hypersecretion. Insulin autoimmune syndrome (IAS) denotes hyperinsulinemic hypoglycemia due to insulin-binding antibodies that prolong insulin half-life. C-peptide clearance is considered to be unaffected, and although a marked C-peptide immunoreactivity in hypoglycemic samples has been reported, it has been suspected to be artifactual. High-resolution mass spectrometry enables examination of the basis of C-peptide-immunoreactivity in IAS. Methods Precipitation of plasma with polyethylene glycol was followed by C-peptide immunoassay. Plasma peptides extracted by solvent precipitation were characterized by nano-LC–MS/MS and analyzed using an untargeted data-dependent method. Peptides related to proinsulin, in amino acid sequence, were identified using proprietary bioinformatics software and confirmed by repeat LC–MS/MS analysis. Gel filtration chromatography coupled to LC–MS/MS was used to identify proinsulin-related peptides present in IAS immunocomplexes. Results were compared with those from C-peptide immunoassay. Results Polyethylene glycol precipitation of IAS plasma, but not control plasma, depleted C-peptide immunoreactivity consistent with immunoglobulin-bound C-peptide immunoreactivity. LC–MS/MS detected proinsulin and des 31,32 proinsulin at higher abundance in IAS plasma compared with control plasma. Analysis by gel filtration chromatography coupled to LC–MS/MS demonstrated proinsulin and des 31,32 proinsulin, but no C-peptide, in plasma immunocomplexes. Conclusions Antibody binding can enrich proinsulin and des 31,32 proinsulin in IAS immunocomplexes. Proinsulin cross-reactivity in some C-peptide immunoassays can lead to artifactually increased C-peptide results.
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Affiliation(s)
- Richard G Kay
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Peter Barker
- Core Biochemical Assay Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Keith Burling
- Core Biochemical Assay Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark Cohen
- Department of Diabetes & Endocrinology, Royal Free London NHS Foundation Trust, London, UK
| | - David Halsall
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Frank Reimann
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK.,National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Fiona M Gribble
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK.,National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Robert K Semple
- University of Edinburgh Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, UK
| | - David Church
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Li Z, Su Y, Yi D, Wu C, Fang W, Wang C. Analysis of the clinical characteristics of insulin autoimmune syndrome induced by alpha-lipoic acid. J Clin Pharm Ther 2021; 46:1295-1300. [PMID: 33821530 DOI: 10.1111/jcpt.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Alpha-lipoic acid (ALA) is widely used as a dietary supplement and antiageing agent. Insulin autoimmune syndrome (IAS) is the most serious adverse reaction reported with the use of ALA. The purpose of this study was to explore the clinical characteristics of ALA-induced IAS and provide a scientific reference for clinical diagnosis, treatment and prevention. METHODS We collected literature on IAS cases induced by ALA for retrospective analysis in Chinese and English. RESULTS AND DISCUSSION The median age of 37 patients (28 females and 9 males) was 61 years (range 32-82). The symptoms occurred at night and in the early morning (60.7%), in the late postprandial period (50.0%) or after fasting (35.7%), within hours in some patients and up to 2 months in others after stopping ALA or during medication treatment. Autonomic nervous system symptoms (81.1%) and neurological hypoglycaemia (64.9%) are the main clinical manifestations of hypoglycaemia. The blood glucose concentration at the onset of hypoglycaemia was 2.19 mmol/L (median, range 1.09-3.52), the insulin concentration was ≥100 μIU/ml (94.6%), and the C-peptide concentration was ≤20 ng/ml (83.3%). Testing for IgG insulin autoantibodies (IAAs) was positive in 37 patients. Pancreatic imaging was unremarkable on computed tomography (CT), magnetic resonance imaging (MRI) and abdominal sonography. Hypoglycaemia disappeared within 5 days to 8 months after withdrawing ALA alone or using corticosteroid treatment. IAA turned negative in 7 months (median; range 2-36). Follow-up showed no recurrent hypoglycaemic episodes at 7.25 months (median; range 1-36). WHAT IS NEW AND CONCLUSION ALA-induced IAS is a clinically rare autoimmune disease with hypoglycaemia that occurs during medication treatment or after drug withdrawal that should be treated promptly.
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Affiliation(s)
- Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yanhong Su
- Department of Pharmacy, Yinan County People's Hospital, Linyi, China
| | - Dan Yi
- Drug clinical trial center, Zhuzhou central hospital, Zhuzhou, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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18
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Liu H, Liang S, Li Y, Fu J, Chen S, Li M, Zhu H, Pan H, Wang O, Yuan T, Mao J, Qin Y, Li Y. A Novel Type of Extreme Insulin Resistance: Nonhypoglycemic Insulin Autoimmune Syndrome. J Clin Endocrinol Metab 2021; 106:1051-1061. [PMID: 33382420 DOI: 10.1210/clinem/dgaa911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Extreme insulin resistance is caused by genetic defects intersecting with the insulin action pathway or by the insulin receptor antibodies. Insulin autoimmune syndrome (IAS) is not considered one of the causes of extreme insulin resistance. OBJECTIVE This work aimed to expand the current knowledge of extreme insulin resistance and to propose the diagnostic criteria and management strategy of a novel type of extreme insulin resistance. METHODS A patient with IAS never experienced hypoglycemia but had persistent hyperglycemia and extreme insulin resistance with treatment with 200 U of intravenous insulin per day. Immunoreactive insulin (IRI), free insulin, and total insulin were measured. The ratio of free insulin to total insulin (insulin-free ratio, IFR) was calculated. RESULTS Extreme insulin resistance has not been reported to be caused by IAS. At admission, IRI and free insulin were undetectable in our patient; total insulin was more than 20 160 pmol/L; and the IFR was lower than 0.03% (control, 90.9%). After adding 500 U porcine insulin to the precipitate containing insulin antibodies, the IRI was still undetectable. Since the patient started glucocorticoid therapy, the free insulin has gradually increased to 11.16 pmol/L, his total insulin has decreased to 5040 pmol/L, and the IFR has increased to 18.26%. Intravenous insulin was stopped, with good glycemic control. CONCLUSION High-affinity insulin autoantibodies with a large capacity can induce a novel type of extreme insulin resistance characterized by extremely high total insulin and very low free insulin levels. The IFR can be used to evaluate therapeutic effects.
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Affiliation(s)
- He Liu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Siyu Liang
- Eight-year Program of Clinical Medicine, PUMCH, CAMS & PUMC), Beijing, China
| | - Yu Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Junling Fu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Shi Chen
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Ming Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Hui Pan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Tao Yuan
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Jiangfeng Mao
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
| | - Yan Qin
- Department of Nephrology, PUMCH, CAMS & PUMC), Beijing, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences (PUMCH, CAMS & PUMC), Beijing, China
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19
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Chin YA, Gardner DSL. Hyperglycaemia converting to persistent hypoglycaemia. Diabet Med 2021; 38:e14519. [PMID: 33434297 DOI: 10.1111/dme.14519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Yun Ann Chin
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
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20
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Žibřidová K, Havlínová B, Svobodová E, Žák P, Čáp J, Gabalec F. Hirata's Disease: Rare Cause of Hypoglycaemia in Caucasian Male. ACTA MEDICA (HRADEC KRALOVE) 2021; 64:50-54. [PMID: 33855960 DOI: 10.14712/18059694.2021.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Insulin autoimmune syndrome or Hirata's disease is an extremely rare condition leading to hypoglycaemia of variable severity due to autoantibodies against insulin. We present the first case documented in the Czech Republic.
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Affiliation(s)
- Kateřina Žibřidová
- 4th Department of Internal Medicine, University Hospital and Faculty of Medicine Hradec Králové, Charles University, Hradec Králové, Czech Republic.
| | - Barbora Havlínová
- 4th Department of Internal Medicine, University Hospital and Faculty of Medicine Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Eliška Svobodová
- 4th Department of Internal Medicine, University Hospital and Faculty of Medicine Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Pavel Žák
- 4th Department of Internal Medicine, University Hospital and Faculty of Medicine Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Jan Čáp
- 4th Department of Internal Medicine, University Hospital and Faculty of Medicine Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Filip Gabalec
- 4th Department of Internal Medicine, University Hospital and Faculty of Medicine Hradec Králové, Charles University, Hradec Králové, Czech Republic
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21
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Sun L, Fang W, Yi D, Sun W, Wang C. Analysis of the clinical characteristics of insulin autoimmune syndrome induced by methimazole. J Clin Pharm Ther 2020; 46:470-475. [PMID: 33119911 DOI: 10.1111/jcpt.13307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/31/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The number of case reports of insulin autoimmune syndrome (IAS) induced by methimazole (MMI) is increasing. The purpose of this study is to explore the clinical characteristics and provide a scientific reference for clinical diagnosis, treatment and prevention. METHODS The literature on IAS cases and case series induced by MMI in Chinese and English was collected for retrospective analysis. RESULTS AND DISCUSSION A total of 106 patients (males 33, females 73) were described in the Chinese and English literature. The median age of patients with IAS induced by MMI was 37 years (range 15-76) occurring during both regular and irregular MMI therapy or after resumption of medication. The onset of symptoms occurred at night or early morning, within days in some and up to 6 months in others; the symptoms were neuropathic in 65.31% and related to the autonomic nervous system in 33.67%. Blood glucose concentration in samples presumably taken during the hypoglycaemic phase was 1.7 mmol/L (median; range 0.03-4.7); insulin concentrations were elevated ≥100 mU/L (ref range) and associated with low C-peptide levels (<10 μg/L; ref range). Tests for IgG insulin autoantibodies (IAA) were positive in 104 patients (98.02%) and negative in two patients (1.98%). The 75-g oral glucose tolerance test (OGTT) showed impaired glucose tolerance and diabetic curves. Pancreatic imaging was unremarkable on computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Withdrawal of MMI alone or with corticosteroid treatment reduced hypoglycaemic episodes within days to 3 months. IAA decreased and became negative in 3 months (median; range 1-12). Follow-up showed no recurrent hypoglycaemic episodes at 5 months (median; range 1-60). WHAT IS NEW AND CONCLUSION Methimazole-induced IAS is a clinically rare autoimmune disease with hypoglycaemia that occurs during medication treatment that should be treated promptly.
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Affiliation(s)
- Linli Sun
- Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Dan Yi
- Drug Clinical Trial Center, Zhuzhou Central Hospital, Zhuzhou, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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22
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Abstract
Diabetes mellitus is a chronic heterogeneous metabolic disorder with complex pathogenesis. It is characterized by elevated blood glucose levels or hyperglycemia, which results from abnormalities in either insulin secretion or insulin action or both. Hyperglycemia manifests in various forms with a varied presentation and results in carbohydrate, fat, and protein metabolic dysfunctions. Long-term hyperglycemia often leads to various microvascular and macrovascular diabetic complications, which are mainly responsible for diabetes-associated morbidity and mortality. Hyperglycemia serves as the primary biomarker for the diagnosis of diabetes as well. In this review, we would be focusing on the classification of diabetes and its pathophysiology including that of its various types.
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Affiliation(s)
- Mujeeb Z Banday
- Department of Biochemistry, Government Medical College and Associated Shri Maharaja Hari Singh Hospital, Srinagar, Kashmir, India
| | - Aga S Sameer
- Department of Basic Medical Sciences, College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, King Abdullah International Medical Research Centre, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Saniya Nissar
- Department of Biochemistry, Government Medical College and Associated Shri Maharaja Hari Singh Hospital, Srinagar, Kashmir, India
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23
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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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24
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Yamada Y, Kitayama K, Oyachi M, Higuchi S, Kawakita R, Kanamori Y, Yorifuji T. Nationwide survey of endogenous hyperinsulinemic hypoglycemia in Japan (2017-2018): Congenital hyperinsulinism, insulinoma, non-insulinoma pancreatogenous hypoglycemia syndrome and insulin autoimmune syndrome (Hirata's disease). J Diabetes Investig 2020; 11:554-563. [PMID: 31742894 PMCID: PMC7232294 DOI: 10.1111/jdi.13180] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/02/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
AIMS/INTRODUCTION We aimed to investigate the nationwide incidence, treatment details and outcomes of patients with endogenous hyperinsulinemic hypoglycemia (EHH), including those with transient/persistent congenital hyperinsulinism (CHI), insulinoma, non-insulinoma pancreatogenous hypoglycemia syndrome and insulin autoimmune syndrome (Hirata's disease) in Japan. MATERIALS AND METHODS A nationwide, questionnaire-based survey was carried out to determine the number of patients with EHH who were treated for hypoglycemia or hypoglycemia-related complications in 2017-2018. The questionnaires were sent to all hospitals in Japan with >300 beds, and with pediatric and/or adult clinics likely managing EHH patients. The secondary questionnaires were sent to obtain the patients' date of birth, sex, age at onset, treatment details and post-treatment outcomes. RESULTS A total of 447 patients with CHI (197 transient CHI, 225 persistent CHI and 25, unknown histology), 205 with insulinoma (118 benign, 18 malignant and 69 unknown subtype), 111 with non-insulinoma pancreatogenous hypoglycemia syndrome (33 post-gastric surgery HH, 57 postprandial HH, 10 nesidioblastosis and 11 unknown subtype) and 22 with insulin autoimmune syndrome were identified. Novel findings included: (i) marked improvement in the prognosis of persistent CHI over the past 10 years; (ii) male dominance in the incidence of transient CHI; (iii) non-insulinoma pancreatogenous hypoglycemia syndrome emerging as the second most common form of EHH in adults; (iv) frequent association of diabetes mellitus with insulin autoimmune syndrome; and (v) frequent post-treatment residual hypoglycemia and impaired quality of life. CONCLUSIONS The first nationwide, all age group survey of EHH showed the current status of each type of EHH disorder and the unmet needs of the patients.
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Affiliation(s)
- Yuki Yamada
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Kana Kitayama
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Maki Oyachi
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Shinji Higuchi
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Rie Kawakita
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Yutaka Kanamori
- Division of SurgeryNational Center for Child Health and DevelopmentTokyoJapan
| | - Tohru Yorifuji
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
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25
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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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Jiang Y, Wang L, Shi F, Zhou H, Zheng J, Cai J, Yang S, Ma J, Liu W. Insulin Autoimmune Syndrome After Exposure to Clopidogrel: A Case Report. Endocr Metab Immune Disord Drug Targets 2019; 20:1355-1362. [PMID: 31858916 DOI: 10.2174/1871530320666191220111615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia that is characterized by hyperinsulinemia, hypoglycemia, and a high autoantibody titer. About 50% of patients with IAS have taken a medication containing sulfhydryl (-SH) groups. We present a case of IAS that developed after taking clopidogrel, a drug with an active metabolite that contains an SH-group. CASE REPORT IAS was suspected in a 63-year-old Chinese man because of high concentrations of insulin and C-peptide during hypoglycemic episodes, and positivity for anti-insulin autoantibody (IAA). During his first episode of hypoglycemia, no trigger medication was identified and prednisone therapy was effective. However, imaging examination revealed a colonic carcinoma and the patient was discharged to undergo surgery. He had no episodes of hypoglycemia for 10 weeks after discontinuation of the prednisone, but then hypoglycemia recurred. A review of his medication revealed that he had taken a 10-day course of clopidogrel just before the recurrence. Therefore, a specialized multidisciplinary team consisting of endocrinologists, dieticians, and clinical pharmacists took charge of his management. Prednisone therapy was restarted and tapered off over 16 weeks. The patient also consumed small, frequent, low-carbohydrate meals and was instructed to avoid trigger medications. No further episodes of hypoglycemia were detected. His insulin and C-peptide concentrations and his anti-IAA index normalized during the follow-up period. CONCLUSION SH-group-containing drugs might induce or exacerbate hypoglycemia in patients with a history of IAS. Furthermore, patients with IAS can benefit from multidisciplinary team management. We suggest herein an evaluation process for patients suspected of IAS.
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Affiliation(s)
- Yihong Jiang
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Lihua Wang
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Fanghong Shi
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Huan Zhou
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Jun Zheng
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Jie Cai
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Shuang Yang
- Department of Clinical Laboratory, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Jing Ma
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China.,China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Liu
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
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Dos Santos TJ, Passone CGB, Ybarra M, Ito SS, Teles MG, Manna TD, Damiani D. Pitfalls in the diagnosis of insulin autoimmune syndrome (Hirata's disease) in a hypoglycemic child: a case report and review of the literature. J Pediatr Endocrinol Metab 2019; 32:421-428. [PMID: 30862762 DOI: 10.1515/jpem-2018-0441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/29/2019] [Indexed: 11/15/2022]
Abstract
Background Insulin autoimmune syndrome (IAS) is a rare cause of hyperinsulinemic hypoglycemia (HH) not addressed as a potential differential diagnosis in current pediatric guidelines. We present a case of IAS in a child with no previous history of autoimmune disease, no previous intake of triggering medications and absence of genetic predisposition. Case presentation A 6-year-old boy presented with recurrent HH (blood glucose of 26 mg/dL [1.4 mmol/L] and insulin of 686 μU/mL). Abdominal imaging was normal. After multiple therapeutic failures, we hypothesized misuse of exogenous insulin and factitious hypoglycemia. Council of Guardianship had the child separated from his mother, but insulin levels remained high. A chromatography test was then performed which showed high titers of endogenous insulin autoantibody (IAA) with early dissociation from the insulin molecule. The human leukocyte antigen (HLA) test showed a DRB1 *13:01/*08:02 genotype. The patient was advised to control food intake and physical activity routines. During a 5-year follow-up, hypoglycemic episodes were sparse, despite high insulin levels. Conclusions Misdiagnosis of IAS with factitious hypoglycemia may happen if IAS is not considered as a differential diagnosis, leading to potential traumatic consequences. Further efforts should be made to increase awareness of IAS as a differential diagnosis of hypoglycemia and to include it in pediatric guidelines.
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Affiliation(s)
- Tiago Jeronimo Dos Santos
- Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
| | - Caroline Gouvêa Buff Passone
- Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
| | - Marina Ybarra
- Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
| | - Simone Sakura Ito
- Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
| | - Milena Gurgel Teles
- Unidade de Diabetes/Unidade de Genética (LIM/25), Disciplina de Endocrinologia, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo/SP, Brazil.,Diabetes Center, Fleury Institute, São Paulo/SP, Brazil
| | - Thais Della Manna
- Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
| | - Durval Damiani
- Pediatric Endocrinology Unit, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil
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Kobayashi S, Amano H, Kawaguchi Y, Yokoo T. A novel treatment of hyperinsulinemic hypoglycemia induced by insulin antibodies with alkali administration: a case report. J Med Case Rep 2019; 13:79. [PMID: 30853027 PMCID: PMC6410487 DOI: 10.1186/s13256-019-1989-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/21/2019] [Indexed: 11/21/2022] Open
Abstract
Background Insulin autoimmune syndrome is a rare cause of hyperinsulinemic hypoglycemia characterized by autoantibodies to human insulin without previous insulin use. We report a case of a patient with hyperinsulinemic hypoglycemia possibly caused by insulin antibodies induced by insulin analogs and a novel therapeutic measure for this condition. Case presentation An 84-year-old Japanese man with a 28-year history of type 2 diabetes and chronic kidney disease, treated with biphasic insulin aspart 30, experienced persistent early morning hypoglycemia with daytime hyperglycemia. Despite discontinuation of biphasic insulin aspart 30, the condition persisted even after the patient ate small, frequent meals. Sodium bicarbonate was administered to correct the chronic metabolic acidosis, which then rectified the early morning glucose level. Conclusions We believe this to be the first published case of a therapeutic approach to the treatment of hyperinsulinemic hypoglycemia associated with insulin antibodies that factors in blood pH and the correction of acidosis using sodium bicarbonate, which physicians could consider.
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Affiliation(s)
- Seiji Kobayashi
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan. .,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Houichi Amano
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Graduate School of Public Health, Teikyo University, Tokyo, Japan
| | - Yoshindo Kawaguchi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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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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30
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Abstract
RATIONALE Insulin autoimmune syndrome (IAS) is a rare endocrine disease characterized by repeated fasting hypoglycemia or episodes of hypoglycemia late after meals, elevated serum insulin, and positivity for insulin autoantibody (IAA) or insulin receptor antibody (IRA). We summarize the clinical manifestations and treatment experiences of 3 patients with IAS. PATIENT CONCERNS One patient with >20-year history of type 2 diabetes mellitus had irregular episodes of hypoglycemia 2 years of after treatment with insulin. Another patient with a 6-year history of type 2 diabetes mellitus presented irregular episodes of hypoglycemia after 6 months of treatment with insulin. One patient with a history of Graves' disease showed hypoglycemia after administration of thiamazole. DIAGNOSIS Serum islet cell antibody (ICA) and glutamic acid decarboxylase antibody (GADA) were negative, while antibody insulin autoantibodies were positive in all the 3 patients. Two patients demonstrated diabetes mellitus after an oral glucose tolerance test, while one had normal glucose tolerance. Furthermore, serum insulin levels significantly elevated and did not matched C peptide levels. No abnormalities were found on enhanced MRI of the pancreas, and all 3 patients were clinically diagnosed with IAS. INTERVENTIONS In case one, insulin aspart 30 injection was withdrawn after admission. In addition, the patient was prescribed sublingual acarbose 3 times daily. Two weeks after admission, prednisone acetate was administered orally once daily at night. In case 2, insulin aspart 30 injection was withdrawn after admission, the patient was prescribed sublingual acarbose 3 times daily with a meal. Five days after admission, oral prednisone acetate was administered once daily at night. In case 3, oral propylthiouracil was prescribed and thiamazole withdrawn after admission, and the patient consumed an extra meal before sleeping. OUTCOMES At the 3-month follow-up visit, the hypoglycemic episodes had disappeared, serum insulin levels were significantly decreased, and insulin antibody (IA) levels were no longer detectable in all 3 patients. LESSONS For those patients with high-insulin hypoglycemia, IAA should be evaluated if serum insulin concentrations are inconsistent with C peptide levels. Therapeutically, a lower dose of glucocorticoids with more appropriate medication timing can be used to achieve good results.
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Reis MZR, Fernandes VO, Fontenele EGP, Sales APAM, Montenegro Junior RM, Quidute ARP. Insulin autoimmune syndrome in an occidental woman: a case report and literature review. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:566-570. [PMID: 30462811 PMCID: PMC10118656 DOI: 10.20945/2359-3997000000078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/02/2018] [Indexed: 11/23/2022]
Abstract
Insulin autoimmune syndrome (IAS, Hirata's disease) is a rare hypoglycemic disorder characterized by spontaneous hypoglycemia associated with extremely high circulating insulin levels and positive anti-insulin antibody results. Thus far, most cases have been reported in Asian countries, notably Japan, with few cases reported in western countries. As a possible cause, it is associated with the use of drugs containing sulfhydryl radicals, such as captopril. This report refers to a 63-year-old female Brazilian patient with a history of postprandial hypoglycemia. After extensive investigation and exclusion of other causes, her hyperinsulinemic hypoglycemia was considered to have likely been induced by captopril. Most cases of IAS are self-limiting. However, dietary management, corticosteroids, plasmapheresis, and rituximab have already been used to treat patients with IAS. In our case, after discontinuation of captopril, an initial decrease in insulin autoantibody levels was observed followed by improvement in episodes of hypoglycemia. Although it is a rare disease, IAS should be considered in the differential diagnosis of endogenous hyperinsulinemic hypoglycemia. Patients with suspected IAS must be screened for autoimmunity-related drugs for insulin. Initial clinical suspicion of IAS can avoid unnecessary costs associated with imaging examinations and/or invasive surgical procedures.
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Affiliation(s)
- Mariella Zaiden Rezende Reis
- Serviço de Endocrinologia e Diabetes, Hospital Universitário Walter Cantídio - Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Virgínia Oliveira Fernandes
- Serviço de Endocrinologia e Diabetes, Hospital Universitário Walter Cantídio - Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Eveline Gadelha Pereira Fontenele
- Serviço de Endocrinologia e Diabetes, Hospital Universitário Walter Cantídio - Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil.,Núcleo de Pesquisa e Desenvolvimento de Medicamentos (NPDM), Departamento de Medicina, Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Ana Paula Abreu Martins Sales
- Serviço de Endocrinologia e Diabetes, Hospital Universitário Walter Cantídio - Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil.,Faculdade de Medicina, Universidade de Fortaleza (Unifor), Fortaleza, CE, Brasil
| | - Renan Magalhães Montenegro Junior
- Serviço de Endocrinologia e Diabetes, Hospital Universitário Walter Cantídio - Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
| | - Ana Rosa Pinto Quidute
- Serviço de Endocrinologia e Diabetes, Hospital Universitário Walter Cantídio - Faculdade de Medicina, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil.,Núcleo de Pesquisa e Desenvolvimento de Medicamentos (NPDM), Faculdade de Medicina, Departamento de Fisiologia e Farmacologia, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brasil
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Church D, Cardoso L, Kay RG, Williams CL, Freudenthal B, Clarke C, Harris J, Moorthy M, Karra E, Gribble FM, Reimann F, Burling K, Williams AJK, Munir A, Jones TH, Führer D, Moeller LC, Cohen M, Khoo B, Halsall D, Semple RK. Assessment and Management of Anti-Insulin Autoantibodies in Varying Presentations of Insulin Autoimmune Syndrome. J Clin Endocrinol Metab 2018; 103:3845-3855. [PMID: 30085133 PMCID: PMC6179165 DOI: 10.1210/jc.2018-00972] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/26/2018] [Indexed: 01/01/2023]
Abstract
Context Insulin autoimmune syndrome (IAS), spontaneous hyperinsulinemic hypoglycemia due to insulin-binding autoantibodies, may be difficult to distinguish from tumoral or other forms of hyperinsulinemic hypoglycemia, including surreptitious insulin administration. No standardized treatment regimen exists. Objectives To evaluate an analytic approach to IAS and responses to different treatments. Design and Setting Observational study in the UK Severe Insulin Resistance Service. Patients Six patients with hyperinsulinemic hypoglycemia and detectable circulating anti-insulin antibody (IA). Main Outcome Measures Glycemia, plasma insulin, and C-peptide concentrations by immunoassay or mass spectrometry (MS). Immunoreactive insulin was determined in the context of polyethylene glycol (PEG) precipitation and gel filtration chromatography (GFC). IA quantification using ELISA and RIA, and IA were further characterized using radioligand binding studies. Results All patients were diagnosed with IAS (five IgG, one IgA) based on a high insulin/C-peptide ratio, low insulin recovery after PEG precipitation, and GFC evidence of antibody-bound insulin. Neither ELISA nor RIA result proved diagnostic for every case. MS provided a more robust quantification of insulin in the context of IA. One patient was managed conservatively, four were treated with diazoxide without sustained benefit, and four were treated with immunosuppression with highly variable responses. IA affinity did not appear to influence presentation or prognosis. Conclusions IAS should be considered in patients with hyperinsulinemic hypoglycemia and a high insulin/C-peptide ratio. Low insulin recovery on PEG precipitation supports the presence of insulin-binding antibodies, with GFC providing definitive confirmation. Immunomodulatory therapy should be customized according to individual needs and clinical response.
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Affiliation(s)
- David Church
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Academic Endocrine Unity, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Richard G Kay
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
| | - Claire L Williams
- Diabetes & Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Bernard Freudenthal
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Catriona Clarke
- Department of Clinical Biochemistry, Western General Hospital, NHS Lothian, Edinburgh, United Kingdom
| | - Julie Harris
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Myuri Moorthy
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Efthmia Karra
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Fiona M Gribble
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Frank Reimann
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Keith Burling
- Core Biochemical Assay Laboratory, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Alistair J K Williams
- Diabetes & Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Alia Munir
- Department of Endocrinology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - T Hugh Jones
- Robert Hague Centre for Diabetes and Endocrinology, Barnsley Hospital, NHS Foundation Trust, Barnsley, United Kingdom
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lars C Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Mark Cohen
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - Bernard Khoo
- Department of Diabetes & Endocrinology, Royal Free Hospital, London, NHS Foundation Trust, London, United Kingdom
| | - David Halsall
- Department of Clinical Biochemistry and Immunology, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, United Kingdom
| | - Robert K Semple
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust–MRC Institute of Metabolic Science, Cambridge, United Kingdom
- National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
- University of Edinburgh Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, United Kingdom
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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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Rare Cause of Recurrent Hypoglycemia: Insulin Autoimmune Syndrome. Case Rep Endocrinol 2018; 2017:6423852. [PMID: 29318060 PMCID: PMC5727552 DOI: 10.1155/2017/6423852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/18/2017] [Indexed: 11/17/2022] Open
Abstract
We report a case of insulin autoimmune syndrome associated with several autoantibodies, presenting with recurrent hypoglycemia, predominantly in the postprandial period, which improved by dietary management and spontaneously resolved within two months. Differentiation from other causes of hyperinsulinemic hypoglycemia, such as insulinoma, is important to avoid unnecessary invasive procedures or surgical interventions. The 75-gram oral glucose tolerance test (OGTT) and mixed meal test showed a typical pattern, which may be useful indirect evidence of insulin autoimmune syndrome.
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Rajpal A, Kassem LS, Moscoso-Cordero M, Arafah BM. Clopidogrel-Induced Insulin Autoimmune Syndrome: A Newly Recognized Cause of Hypoglycemia in a Patient Without Diabetes. J Endocr Soc 2017; 1:1217-1223. [PMID: 29264578 PMCID: PMC5686698 DOI: 10.1210/js.2017-00316] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 08/23/2017] [Indexed: 01/27/2023] Open
Abstract
Insulin autoimmune syndrome (IAS), defined as hyperinsulinemic hypoglycemia with high titers of anti-insulin antibodies, is frequently reported in Japanese patients but rarely observed in whites. We report in this study on a 79-year-old white male without diabetes who developed IAS following exposure to clopidogrel, a drug not previously known to cause hypoglycemia. The patient presented with recurrent symptomatic hypoglycemia. During one episode, serum glucose was 45 mg/dL, whereas insulin and C-peptide levels were 40,000 mIU/mL and 40 ng/mL, respectively. Additional studies revealed no intake of insulin or its secretagogues, whereas anti-insulin antibody titer was high (59.3 nmol/L). Although total insulin levels were consistently high, free insulin concentrations (polyethylene glycol precipitation) were appropriate for ambient glycemia. The patient was found to have HLA-DRB1*0404, a feature often reported in Japanese patients with IAS. Three weeks prior to symptom onset, he was started on clopidogrel, a drug that does not have a sulfhydryl group, but its active metabolite does. Clopidogrel was switched to a nonsulfhydryl antiplatelet agent, and glucocorticoid therapy was initiated. Shortly thereafter, the frequency of hypoglycemic episodes decreased, and glucocorticoids were tapered over the ensuing 3 months. No hypoglycemic episodes were noted during 6 months of observation after discontinuing glucocorticoids, whereas the total insulin and anti-insulin antibody levels normalized. The data indicate that IAS should be considered in the differential diagnosis of hyperinsulinemic hypoglycemia in seemingly well individuals, even when no drugs known to cause IAS were used. Clinical suspicion of IAS can avoid expensive imaging and unnecessary surgery in affected patients.
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Affiliation(s)
- Aman Rajpal
- Division of Clinical and Molecular Endocrinology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio 44106
| | - Laure Sayyed Kassem
- Division of Clinical and Molecular Endocrinology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio 44106
| | - Maria Moscoso-Cordero
- Division of Clinical and Molecular Endocrinology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio 44106
| | - Baha M Arafah
- Division of Clinical and Molecular Endocrinology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio 44106
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Ambigapathy J, Sahoo J, Kamalanathan S. Autoimmune hypoglycemia in type 1 diabetes mellitus. Indian Pediatr 2017; 54:593-594. [DOI: 10.1007/s13312-017-1075-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wada K, Uchida HA, Wada Y. Poor glycemic control attributable to insulin antibody in a fulminant type 1 diabetes patient under hemodialysis: successful treatment with double filtration plasmapheresis and prednisolone. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0096-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Church D, Cardoso L, Bradbury S, Clarke C, Stears A, Dover A, Halsall D, Semple R. Diagnosis of insulin autoimmune syndrome using polyethylene glycol precipitation and gel filtration chromatography with ex vivo insulin exchange. Clin Endocrinol (Oxf) 2017; 86:347-353. [PMID: 27588366 PMCID: PMC5324546 DOI: 10.1111/cen.13179] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
Abstract
CONTEXT Insulin-binding antibodies may produce severe dysglycaemia in insulin-naïve patients ('insulin autoimmune syndrome' (IAS) or Hirata disease), while rendering routine insulin assays unreliable. OBJECTIVE To assess the performance of clinically used insulin assays and an optimal analytical approach in the context of IAS. DESIGN Observational biochemical study of selected patients with hyperinsulinaemic hypoglycaemia. PATIENTS Three patients without diabetes with recurrent spontaneous hyperinsulinaemic hypoglycaemia and 'positive' insulin antibodies. MEASUREMENTS A panel of clinically used insulin assays (Siemens ADVIA® Centaur, Siemens Immulite® 2000, DiaSorin LIAISON® XL, PE AutoDELFIA® and the Beckman Coulter Access® 2) were used before and after plasma dilution or polyethylene glycol (PEG) precipitation. Anti-insulin IgG antibodies were measured by Isletest™ -IAA ELISA. Gel filtration chromatography (GFC) was undertaken with and without preincubation of plasma with exogenous insulin. RESULTS Dilution of IAS plasma with assay-specific buffer increased insulin recovery, supporting negative immunoassay interference by antibodies. PEG precipitation of IAS plasma decreased insulin recovery using all assays except the Immulite® 2000. GFC discriminated high molecular weight and monomeric insulin, while ex vivo addition of exogenous insulin to plasma increased insulin bound to antibody, thereby improving the sensitivity of detection of insulin immunocomplexes. CONCLUSIONS Immunoprecipitation with PEG must be used with caution in screening for insulin-antibody complexes as results are assay dependent. GFC with addition of exogenous insulin can identify significant insulin immunocomplexes with enhanced sensitivity, with attendant greater clinical utility and avoidance of radiolabelled reagents.
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Affiliation(s)
- David Church
- The University of Cambridge Metabolic Research LaboratoriesWellcome Trust‐MRC Institute of Metabolic ScienceCambridgeUK
- The National Institute for Health Research Cambridge Biomedical Research CentreCambridgeUK
- The Pathology PartnershipDepartment of Clinical Biochemistry and ImmunologyAddenbrooke's HospitalCambridgeUK
| | - Luís Cardoso
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Sonia Bradbury
- The Pathology PartnershipDepartment of Clinical Biochemistry and ImmunologyAddenbrooke's HospitalCambridgeUK
| | - Catriona Clarke
- Department of Clinical BiochemistryWestern General HospitalNHS LothianEdinburghUK
| | - Anna Stears
- Cambridge University Hospitals NHS Foundation TrustCambridge Biomedical CampusCambridgeUK
| | - Anna Dover
- Edinburgh Centre for Endocrinology and DiabetesRoyal Infirmary of EdinburghEdinburghUK
| | - David Halsall
- The Pathology PartnershipDepartment of Clinical Biochemistry and ImmunologyAddenbrooke's HospitalCambridgeUK
| | - Robert Semple
- The University of Cambridge Metabolic Research LaboratoriesWellcome Trust‐MRC Institute of Metabolic ScienceCambridgeUK
- The National Institute for Health Research Cambridge Biomedical Research CentreCambridgeUK
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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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Pavithran PV, Bhavani N, Jayakumar RV, Menon AS, Kumar H, Menon VU, Nair V, Abraham N. Autoantibodies to Insulin and Dysglycemia in People With and Without Diabetes: An Underdiagnosed Association. Clin Diabetes 2016; 34:164-7. [PMID: 27621535 PMCID: PMC5019007 DOI: 10.2337/diaclin.34.3.164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Nisha Bhavani
- Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | | | | | - Harish Kumar
- Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Vadayath Usha Menon
- Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Vasantha Nair
- Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Nithya Abraham
- Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
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Peters C, Nirmalaraj K. Long-Term Prevention of Hypoglycemia by Conservatively Managed Insulin Autoimmune Syndrome. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15991.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Han JS, Moon HJ, Kim JS, Kim HI, Kim CH, Kim MJ. Anti-tuberculosis Treatment-Induced Insulin Autoimmune Syndrome. THE EWHA MEDICAL JOURNAL 2016. [DOI: 10.12771/emj.2016.39.4.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jung Suk Han
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Han Ju Moon
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Seo Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Hong Il Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Cheol Hyeon Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Min Joo Kim
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
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Raizada N, Rahaman SH, Kandasamy D, Jyotsna VP. Rare association of insulin autoimmune syndrome with ankylosing spondylitis. Endocrinol Diabetes Metab Case Rep 2015; 2015:150090. [PMID: 26527431 PMCID: PMC4626647 DOI: 10.1530/edm-15-0090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 09/24/2015] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Nishant Raizada
- Department of Endocrinology and Metabolism , All India Institute of Medical Sciences , New Delhi , India
| | - S H Rahaman
- Department of Endocrinology and Metabolism , All India Institute of Medical Sciences , New Delhi , India
| | - D Kandasamy
- Department of Radiology , All India Institute of Medical Sciences , New Delhi , India
| | - V P Jyotsna
- Department of Endocrinology and Metabolism , All India Institute of Medical Sciences , New Delhi , India
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Lichtman MA, Balderman SR. Unusual Manifestations of Essential Monoclonal Gammopathy. II. Simulation of the Insulin Autoimmune Syndrome. Rambam Maimonides Med J 2015; 6:RMMJ.10212. [PMID: 26241232 PMCID: PMC4524400 DOI: 10.5041/rmmj.10212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In rare cases, the monoclonal immunoglobulin that characterizes essential monoclonal gammopathy interacts with a self-antigen with functional consequences and a resulting clinical syndrome. This event is presumably random and results from the clone of B lymphocytes making a monoclonal immunoglobulin that simulates an autoimmune antibody. Thus, by chance, the monoclonal immunoglobulin has sufficient affinity for an epitope on a normal protein that functional consequences ensue. One such rare event is the synthesis and secretion of a monoclonal immunoglobulin that binds to human insulin. Inactivation of insulin by antibody results in (1) an early postprandial hyperglycemia, (2) followed by either or both (i) a reactive overshot in insulin secretion, as a result of hypertrophied or hyperplastic islet beta cells, later falling glucose levels, and (ii) an unpredictable dissociation of insulin from the complex, and, several hours later, (3) a resultant increase in free insulin levels and severe hypoglycemia with clinical consequences, ranging from sweating, dizziness, headache, and tremors to confusion, seizures, and unconsciousness. These attacks are invariably responsive to glucose administration. This very uncommon manifestation of a monoclonal gammopathy can occur in patients with essential monoclonal gammopathy or myeloma. The monoclonal anti-insulin immunoglobulin in monoclonal gammopathy has a low affinity for insulin, but has a high capacity for insulin-binding, resulting in the syndrome of episodic hypoglycemic attacks. This phenomenon of an insulin-binding monoclonal immunoglobulin simulates the acquired insulin autoimmune syndrome, although the latter is mediated by a polyclonal antibody response in the majority of cases studied, and has linkage to HLA class II alleles.
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Affiliation(s)
- Marshall A. Lichtman
- Professor of Medicine and of Biochemistry and Biophysics, Department of Medicine and James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
- To whom correspondence should be addressed. E-mail:
| | - Sophia R. Balderman
- Instructor in Medicine, Department of Medicine and James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
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Savas-Erdeve S, Yılmaz Agladioglu S, Onder A, Peltek Kendirci HN, Bas VN, Sagsak E, Cetinkaya S, Aycan Z. An uncommon cause of hypoglycemia: insulin autoimmune syndrome. Horm Res Paediatr 2015; 82:278-82. [PMID: 25060673 DOI: 10.1159/000362758] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 04/08/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a condition characterized by hypoglycemia associated with the presence of autoantibodies to insulin in patients who have not been injected with insulin. CASE REPORT A female patient (aged 16 years and 3 months) presented with the complaint of being overweight. Physical examination revealed a body weight of 78.2 kg (+2.6 SD) and a height of 167 cm (+0.73 SD). While the patient's fasting blood glucose level was found to be 40 mg/dl, blood ketone was negative and the serum insulin level was determined as 379 mIU/ml. The patient was diagnosed with hyperinsulinemic hypoglycemia. Abdominal ultrasound, pancreas MRI and endoscopic ultrasound were normal. The daily blood glucose profile revealed postprandial hyperglycemia and reactive hypoglycemia in addition to fasting hypoglycemia. The results of anti-insulin antibody measurements were as high as 41.8% (normal range 0-7%). A 1,600-calorie diet containing 40% carbohydrate and divided into 6 meals a day was given to the patient. Simple sugars were excluded from the diet. Hypoglycemic episodes were not observed, but during 2 years of observation, serum levels of insulin and anti-insulin antibodies remained elevated. CONCLUSION In all hyperinsulinemic hypoglycemia cases, IAS should be considered in the differential diagnosis and insulin antibody measurements should be carried out.
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Affiliation(s)
- Senay Savas-Erdeve
- Pediatric Endocrinology Division, Dr. Sami Ulus Training and Research Children's Hospital, Ankara, Turkey
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Woo CY, Jeong JY, Jang JE, Leem J, Jung CH, Koh EH, Lee WJ, Kim MS, Park JY, Lee JB, Lee KU. Clinical features and causes of endogenous hyperinsulinemic hypoglycemia in Korea. Diabetes Metab J 2015; 39:126-31. [PMID: 25922806 PMCID: PMC4411543 DOI: 10.4093/dmj.2015.39.2.126] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/24/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Endogenous hyperinsulinemic hypoglycemia (EHH) is characterized by an inappropriately high plasma insulin level, despite a low plasma glucose level. Most of the EHH cases are caused by insulinoma, whereas nesidioblastosis and insulin autoimmune syndrome (IAS) are relatively rare. METHODS To evaluate the relative frequencies of various causes of EHH in Korea, we retrospectively analyzed 84 patients who were diagnosed with EHH from 1998 to 2012 in a university hospital. RESULTS Among the 84 EHH patients, 74 patients (88%), five (6%), and five (6%) were diagnosed with insulinoma, nesidioblastosis or IAS, respectively. The most common clinical manifestation of EHH was neuroglycopenic symptoms. Symptom duration before diagnosis was 14.5 months (range, 1 to 120 months) for insulinoma, 1.0 months (range, 6 days to 7 months) for nesidioblastosis, and 2.0 months (range, 1 to 12 months) for IAS. One patient, who was diagnosed with nesidioblastosis in 2006, underwent distal pancreatectomy but was later determined to be positive for insulin autoantibodies. Except for one patient who was diagnosed in 2007, the remaining three patients with nesidioblastosis demonstrated severe hyperinsulinemia (157 to 2,719 µIU/mL), which suggests that these patients might have had IAS, rather than nesidioblastosis. CONCLUSION The results of this study suggest that the prevalence of IAS may be higher in Korea than previously thought. Therefore, measurement of insulin autoantibody levels is warranted for EHH patients, especially in patients with very high plasma insulin levels.
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Affiliation(s)
- Chang-Yun Woo
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yun Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Eun Jang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaechan Leem
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hee Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hee Koh
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Je Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seon Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong-Yeol Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Bok Lee
- Department of Statistics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Up Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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Quan H, Tan H, Li Q, Li J, Li S. Immunological hypoglycemia associated with insulin antibodies induced by exogenous insulin in 11 Chinese patients with diabetes. J Diabetes Res 2015; 2015:746271. [PMID: 25961056 PMCID: PMC4413037 DOI: 10.1155/2015/746271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate the characteristics of immunological hypoglycemia associated with insulin antibodies (IAbs) induced by exogenous insulin in Chinese patients with diabetes. METHODS The clinical data of patients with immunological hypoglycemia due to IAbs were retrospectively analyzed by screening patients with diabetes discharged from West China Hospital from 2007 to 2013. RESULTS A total of 11 patients (eight men and three women) were identified. Insulin-C-peptide separation was found in all patients via insulin and C-peptide release test. Previous insulin use was ceased after admission and was switched to oral hypoglycemic agents (OHAs) (8/11), lifestyle modification only (2/11), or regular human insulin (1/11). Hypoglycemia was ameliorated after a median of 20 days (interquartile range [IQR], 11-40), while IAbs turned negative after a median of 17 months (IQR, 4-19), and serum immunoreactive insulin (IRI) levels dropped substantially after a median of 22 months (IQR, 9-32) in these cases. CONCLUSIONS In insulin-treated patients with unexpected and refractory hypoglycemia even after insulin therapy was gradually reduced or even withdrawn, IAbs induced by exogenous insulin should be considered, and insulin withdrawal might be promptly needed. The course of immunological hypoglycemia was benign and self-limited.
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Affiliation(s)
- Heng Quan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianwei Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
- *Jianwei Li: and
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
- *Sheyu Li:
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Chen PH, Wang JS, Hwang JI, Lin SY, Sheu WHH, Wu YJ, Peng CM, Lee IT. Insulinoma in a young female patient with systemic lupus erythematosus: a case report. Endocr Pract 2014; 20:e256-9. [PMID: 25148817 DOI: 10.4158/ep14181.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Fasting hypoglycemia may occur in subjects with systemic lupus erythematosus (SLE) when accompanied with insulin-binding antibodies or insulin-receptor antibodies. However, insulinoma has not been reported in SLE subjects with hypoglycemia. METHODS We present a case report and review the relevant literature. RESULTS A 26-year-old female with underlying SLE experienced several episodes of neuropsychiatric symptoms in a fasting state. The steroid dosage was titrated up, but in vain. Timely imaging studies showed a pancreatic tumor, and insulinoma was proven by pathology. Hypoglycemia did not recur after surgery. CONCLUSION Physicians should distinguish insulinoma from autoimmunity-mediated hypoglycemia in SLE patients with fasting hypoglycemia.
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Affiliation(s)
- Po-Hsun Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jun-Sing Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-I Hwang
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Yi Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wayne H-H Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ya-Ju Wu
- Department of Pathology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Ming Peng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - I-Te Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan School of Medicine, National Yang-Ming University, Taipei, Taiwan School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Gullo D, Evans JL, Sortino G, Goldfine ID, Vigneri R. Insulin autoimmune syndrome (Hirata Disease) in European Caucasians taking α-lipoic acid. Clin Endocrinol (Oxf) 2014; 81:204-9. [PMID: 24111525 DOI: 10.1111/cen.12334] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/31/2013] [Accepted: 09/12/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Lipoic acid (LA) is a widely used nutritional supplement and is sometimes used as an adjuvant treatment for diabetic neuropathy and other conditions. Insulin autoimmune syndrome (IAS, Hirata disease) is a rare cause of spontaneous hypoglycaemia, extremely high serum insulin levels and high titres of autoantibodies against endogenous insulin despite no prior exposure to exogenous insulin. In Japanese individuals, IAS is associated with the human leucocyte antigen (HLA) HLA-DRB1*04:06 allele and often occurs upon exposure to sulphhydryl-containing compounds including LA. Only one case has been reported in Caucasians. We now report six Caucasian patients taking LA with IAS and describe a unique HLA subtype in these patients. RESEARCH DESIGN AND METHODS Six Caucasian patients (M = 3; F = 3), median age 63 years, presented with spontaneous episodes of fasting and postabsorptive hypoglycaemia associated with mainly neuroglycopenic symptoms. No patient was treated with insulin or had an insulinoma. Hypoglycaemic symptoms appeared 30 and 120 days after taking lipoic acid (LA; 600 mg/day). Case histories and standard laboratory analyses were utilized. RESULTS Discontinuation of LA resulted in a reduction in hypoglycaemic episodes. All patients were treated with oral or iv glucose and prednisone (12.5-25 mg/day). HLA analysis revealed the HLA-DRB1*04:03 allele in five patients, while the HLA-DRB1*04:06 allele was present in one patient. CONCLUSIONS This is the first report of LA-related IAS in Caucasians who possess the HLA-DRB1*04:03 allele, implicating this allele in the genetic susceptibility to IAS in Caucasians. The greater occurrence of the HLA-DRB1*04:03 allele in Caucasian and other populations, combined with the growing use of LA in developed countries, may be a future predictor of additional cases of IAS.
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Affiliation(s)
- Damiano Gullo
- Endocrinologia, Garibaldi-Nesima Medical Center and University of Catania, Catania, Italy
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50
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Philippon M, Sejil S, Mugnier M, Rocher L, Guibergia C, Vialettes B, Delenne B. Use of the continuous glucose monitoring system to treat insulin autoimmune syndrome: quantification of glucose excursions and evaluation of treatment efficacy. Diabet Med 2014; 31:e20-4. [PMID: 25077287 DOI: 10.1111/dme.12418] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Autoimmune hypoglycaemia, based on the presence of autoantibodies directed against endogenous insulin (insulin autoimmune syndrome or Hirata's disease), is a rare cause of hypoglycaemia. Treatment of the disease is not standardized and various therapeutic options have been proposed. We wondered whether using a continuous glucose-monitoring system could help quantify precisely glucose excursions and allow evaluation of treatment efficacy. CASE REPORT A 44-year-old Caucasian patient with insulin autoimmune syndrome was studied for 7 days using a continuous glucose monitoring system under various treatment regimens, i.e. diet modification, high-dose corticosteroids, alpha-glucosidase inhibitors, and plasmapheresis. CONCLUSION Continuous glucose monitoring system data confirmed that insulin autoimmune syndrome alternated between periods of prandial hyperglycaemia and interprandial hypoglycaemia. Alpha glucosidase inhibitors and plasmapheresis were more potent in limiting glucose excursions than corticosteroid or diet-only treatments. The continuous glucose monitoring system appears to be a useful tool in the management of insulin autoimmune syndrome.
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