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Carsote M, Nistor C, Gheorghe AM, Sima OC, Trandafir AI, Nistor TVI, Sandulescu BA, Ciobica ML. Turning Points in Cross-Disciplinary Perspective of Primary Hyperparathyroidism and Pancreas Involvements: Hypercalcemia-Induced Pancreatitis, MEN1 Gene-Related Tumors, and Insulin Resistance. Int J Mol Sci 2024; 25:6349. [PMID: 38928056 PMCID: PMC11203827 DOI: 10.3390/ijms25126349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/13/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
We aimed to provide an in-depth analysis with respect to three turning points in pancreas involvement in primary hyperparathyroidism (PHP): hypercalcemia-induced pancreatitis (HCa-P), MEN1 (multiple endocrine neoplasia)-related neuroendocrine tumors (NETs), and insulin resistance (IR). This was a comprehensive review conducted via a PubMed search between January 2020 and January 2024. HCa-P (n = 9 studies, N = 1375) involved as a starting point parathyroid NETs (n = 7) or pancreatitis (n = 2, N = 167). Case report-focused analysis (N = 27) showed five cases of pregnancy PHP-HCa-P and three reports of parathyroid carcinoma (female/male ratio of 2/1, ages of 34 in women, men of 56). MEN1-NET studies (n = 7) included MEN1-related insulinomas (n = 2) or MEN1-associated PHP (n = 2) or analyses of genetic profile (n = 3), for a total of 877 MEN1 subjects. In MEN1 insulinomas (N = 77), the rate of associated PHP was 78%. Recurrence after parathyroidectomy (N = 585 with PHP) was higher after less-than-subtotal versus subtotal parathyroidectomy (68% versus 45%, p < 0.001); re-do surgery was 26% depending on surgery for pancreatic NETs (found in 82% of PHP patients). MEN1 pathogenic variants in exon 10 represented an independent risk factor for PHP recurrence. A single pediatric study in MEN1 (N = 80) revealed the following: a PHP rate of 80% and pancreatic NET rate of 35% and 35 underlying germline MEN1 pathogenic variants (and 3/35 of them were newly detected). The co-occurrence of genetic anomalies included the following: CDC73 gene variant, glucokinase regulatory protein gene pathogenic variant (c.151C>T, p.Arg51*), and CAH-X syndrome. IR/metabolic feature-focused analysis identified (n = 10, N = 1010) a heterogeneous spectrum: approximately one-third of adults might have had prediabetes, almost half displayed some level of IR as reflected by HOMA-IR > 2.6, and serum calcium was positively correlated with HOMA-IR. Vitamin D deficiency was associated with a higher rate of metabolic syndrome (n = 1). Normocalcemic and mildly symptomatic hyperparathyroidism (n = 6, N = 193) was associated with a higher fasting glucose and some improvement after parathyroidectomy. This multilayer pancreas/parathyroid analysis highlighted a complex panel of connections from pathogenic factors, including biochemical, molecular, genetic, and metabolic factors, to a clinical multidisciplinary panel.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Clinical Endocrinology V, “C.I. Parhon” National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Thoracic Surgery Department, “Dr. Carol Davila” Central Military University Emergency Hospital, 010242 Bucharest, Romania
| | - Ana-Maria Gheorghe
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.G.); (O.-C.S.); (A.-I.T.); (B.-A.S.)
| | - Oana-Claudia Sima
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.G.); (O.-C.S.); (A.-I.T.); (B.-A.S.)
| | - Alexandra-Ioana Trandafir
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.G.); (O.-C.S.); (A.-I.T.); (B.-A.S.)
| | - Tiberiu Vasile Ioan Nistor
- Department of Clinical Biochemistry, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
| | - Bianca-Andreea Sandulescu
- PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.-M.G.); (O.-C.S.); (A.-I.T.); (B.-A.S.)
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
| | - Mihai-Lucian Ciobica
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Internal Medicine I and Rheumatology, “Dr. Carol Davila” Central Military University Emergency Hospital, 010825 Bucharest, Romania
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Ramírez-Rentería C, Hernández-Ramírez LC. Genetic diagnosis in acromegaly and gigantism: From research to clinical practice. Best Pract Res Clin Endocrinol Metab 2024; 38:101892. [PMID: 38521632 DOI: 10.1016/j.beem.2024.101892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
It is usually considered that only 5% of all pituitary neuroendocrine tumours are due to inheritable causes. Since this estimate was reported, however, multiple genetic defects driving syndromic and nonsyndromic somatotrophinomas have been unveiled. This heterogeneous genetic background results in overlapping phenotypes of GH excess. Genetic tests should be part of the approach to patients with acromegaly and gigantism because they can refine the clinical diagnoses, opening the possibility to tailor the clinical conduct to each patient. Even more, genetic testing and clinical screening of at-risk individuals have a positive impact on disease outcomes, by allowing for the timely detection and treatment of somatotrophinomas at early stages. Future research should focus on determining the actual frequency of novel genetic drivers of somatotrophinomas in the general population, developing up-to-date disease-specific multi-gene panels for clinical use, and finding strategies to improve access to modern genetic testing worldwide.
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Affiliation(s)
- Claudia Ramírez-Rentería
- Unidad de Investigación Médica en Enfermedades Endocrinas, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Laura C Hernández-Ramírez
- Red de Apoyo a la Investigación, Universidad Nacional Autónoma de México, e Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Sada V, Puliani G, Feola T, Pirchio R, Pofi R, Sesti F, De Alcubierre D, Amodeo ME, D'Aniello F, Vincenzi L, Gianfrilli D, Isidori AM, Grossman AB, Sbardella E. Tall stature and gigantism in transition age: clinical and genetic aspects-a literature review and recommendations. J Endocrinol Invest 2024; 47:777-793. [PMID: 37891382 DOI: 10.1007/s40618-023-02223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Tall stature is defined as height greater than the threshold of more than 2 standard deviations above the average population height for age, sex, and ethnicity. Many studies have described the main aspects of this condition during puberty, but an analysis of the characteristics that the physician should consider in the differential diagnosis of gigantism-tall stature secondary to a pituitary tumour-during the transition age (15-25 years) is still lacking. METHODS A comprehensive search of English-language original articles was conducted in the MEDLINE database (December 2021-March 2022). We selected all studies regarding epidemiology, genetic aspects, and the diagnosis of tall stature and gigantism during the transition age. RESULTS Generally, referrals for tall stature are not as frequent as expected because most cases are familial and are usually unreported by parents and patients to endocrinologists. For this reason, lacking such experience of tall stature, familiarity with many rarer overgrowth syndromes is essential. In the transition age, it is important but challenging to distinguish adolescents with high constitutional stature from those with gigantism. Pituitary gigantism is a rare disease in the transition age, but its systemic complications are very relevant for future health. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life and prevent comorbidities of individual patient in this age range. CONCLUSION The aim of our review is to provide a practical clinical approach to recognise adolescents, potentially affected by gigantism, as early as possible.
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Affiliation(s)
- V Sada
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - G Puliani
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - T Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - R Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Degli Studi di Napoli "Federico II", Naples, Italy
| | - R Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Oxford Centre for Diabetes, Endocrinology, and Metabolism, Churchill Hospital, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - F Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - M E Amodeo
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - F D'Aniello
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - L Vincenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - D Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Centre for Rare Diseases (ENDO-ERN Accredited), Policlinico Umberto I, Rome, Italy
| | - A B Grossman
- Green Templeton College, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Shariq OA, Abrantes VB, Lu LY, Tebben PJ, Foster TM, Dy BM, Lyden ML, Young WF, McKenzie TJ. Primary hyperparathyroidism in patients with multiple endocrine neoplasia type 1: Impact of genotype and surgical approach on long-term postoperative outcomes. Surgery 2024; 175:8-16. [PMID: 37891063 DOI: 10.1016/j.surg.2023.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/25/2023] [Accepted: 05/24/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Protein-truncating germline pathogenic variants in the N- and C-terminal exons (2, 9, and 10) of the MEN1 gene may be associated with aggressive pancreatic neuroendocrine tumors. However, the impact of these variants on parathyroid disease is poorly understood. We sought to investigate the effects of genotype and surgical approach on clinical phenotype and postoperative outcomes in patients with multiple endocrine neoplasia type 1 (MEN1)-related primary hyperparathyroidism. METHODS We identified patients with MEN1 evaluated at our institution from 1985 to 2020 and stratified them by genotype, (truncating variants in exons 2, 9, or 10, or other variants), and index surgical approach, (less-than-subtotal parathyroidectomy [ RESULTS Of the 209 patients we identified, primary hyperparathyroidism was diagnosed in 194 (93%) and at a younger median age in those with truncating exon 2, 9, or 10 variants compared with other variants (27 years vs 31 years; P = .006). Median disease-free survival was significantly worse in patients who underwent CONCLUSION The MEN1 genotype may affect the age of onset of primary hyperparathyroidism and the time to recurrence after surgery.
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Affiliation(s)
| | | | - Lauren Y Lu
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Peter J Tebben
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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Carsote M, Stanciu M, Popa FL, Gheorghe AM, Ciuche A, Nistor C. Pediatric Neuroendocrine Neoplasia of the Parathyroid Glands: Delving into Primary Hyperparathyroidism. Biomedicines 2023; 11:2810. [PMID: 37893182 PMCID: PMC10603939 DOI: 10.3390/biomedicines11102810] [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: 09/19/2023] [Revised: 10/07/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Our objective was to overview the most recent data on primary hyperparathyroidism (PHP) in children and teenagers from a multidisciplinary perspective. Methods: narrative review based on full-length, English-language papers (from PubMed, between January 2020 and July 2023). Results: 48 papers (14 studies of ≥10 subjects/study, and 34 case reports/series of <10 patients/study). Study-sample-based analysis: except for one case-control study, all of the studies were retrospective, representing both multicenter (n = 5) and single-center (n = 7) studies, and cohort sizes varied from small (N = 10 to 19), to medium-sized (N = 23 to 36) and large (N = 63 to 83); in total, the reviewed studies covered 493 individuals with PHP. Case reports/series (n = 34, N = 41): the mean ages studied varied from 10.2 to 14 years in case reports, and the mean age was 17 years in case series. No clear female predominance was identified, unlike that observed in the adult population. Concerning the assessments, there were four major types of endpoints: imaging data collection, such as ultrasound, 99mTc Sestamibi, or dual-phase computed tomography (CT); gene testing/familial syndrome identification; preoperative findings; and exposure to surgical outcome/preoperative drugs, like cinacalcet, over a 2.2-year median (plus two case reports of denosumab used as an off-label calcium-lowering agent). Single-gland cases (representing 85% of sporadic cases and 19% of genetic PHP cases) showed 100% sensitivity for neck ultrasounds, with 98% concordance with 99mTc Sestamibi, as well as a 91% sensitivity for dual-phase CT, with 25% of the lesions being ectopic parathyroids (mostly mediastinal intra-thymic). Case reports included another 9/41 patients with ectopic parathyroid adenomas, 3/41 with parathyroid carcinomas, and 8/41 subjects with brown tumors. Genetic PHP (which has a prevalence of 5-26.9%) mostly involved MEN1, followed by CDC73, CASR, RET, and CDKN1B, as well as one case of VHL. Symptomatic PHP: 70-100% of all cases. Asymptomatic PHP: 60% of genetic PHP cases. Renal involvement: 10.5% of a cohort with genetic PHP, 71% of sporadic PHP cases; 50% (in a cohort with a mean age of 16.7), 29% (in a cohort with a mean age of 15.2); 0% (in infancy) to 50-62% (in teenagers). Bone anomalies: 83% of the children in one study and 62% of those in two other studies. Gastrointestinal issues: 40% of one cohort, but the data are heterogeneous. Cure rate through parathyroidectomy: 97-98%. Recurrent PHP: 2% of sporadic PHP cases and 38% of familial PHP cases. Hungry bone syndrome: maximum rate of 34-40%. Case reports identified another 7/41 subjects with the same post-parathyroidectomy condition; a potential connection with ectopic presentation or brown tumors is suggested, but there are limited data. Minimally invasive thoracoscopic approaches for ectopic tumors seemed safe. The current level of statistical evidence on pediatric PHP qualifies our study- and case-sample-based analysis (n = 48, N = 534) as one of the largest of its kind. Awareness of PHP is the key factor to benefit our young patients.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania;
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, Victoriei Blvd., 550024 Sibiu, Romania
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, Victoriei Blvd., 550024 Sibiu, Romania
| | - Ana-Maria Gheorghe
- C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania;
- Ph.D. Doctoral School, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Adrian Ciuche
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.C.); (C.N.)
- Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 010825 Bucharest, Romania
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.C.); (C.N.)
- Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 010825 Bucharest, Romania
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Simonds WF. Expressions of Cushing's syndrome in multiple endocrine neoplasia type 1. Front Endocrinol (Lausanne) 2023; 14:1183297. [PMID: 37409236 PMCID: PMC10319112 DOI: 10.3389/fendo.2023.1183297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Cushing's syndrome (CS) resulting from endogenous hypercortisolism can be sporadic or can occur in the context of familial disease because of pituitary or extra-pituitary neuroendocrine tumors. Multiple endocrine neoplasia type 1 (MEN1) is unique among familial endocrine tumor syndromes because hypercortisolism in this context can result from pituitary, adrenal, or thymic neuroendocrine tumors and can therefore reflect either ACTH-dependent or ACTH-independent pathophysiologies. The prominent expressions of MEN1 include primary hyperparathyroidism, tumors of the anterior pituitary, gastroenteropancreatic neuroendocrine tumors, and bronchial carcinoid tumors along with several common non-endocrine manifestations such as cutaneous angiofibromas and leiomyomas. Pituitary tumors are present in about 40% of MEN1 patients, and up to 10% of such tumors secrete ACTH that can result in Cushing's disease. Adrenocortical neoplasms occur frequently in MEN1. Although such adrenal tumors are mostly clinically silent, this category can include benign or malignant tumors causing hypercortisolism and CS. Ectopic tumoral ACTH secretion has also been observed in MEN1, almost exclusively originating from thymic neuroendocrine tumors. The range of clinical presentations, etiologies, and diagnostic challenges of CS in MEN1 are reviewed herein with an emphasis on the medical literature since 1997, when the MEN1 gene was identified.
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Multiple Endocrine Neoplasia in Childhood: An Update on Diagnosis, Screening, Management and Treatment. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Multiple endocrine neoplasia (MEN) is a group of heterogenous syndromes characterized by the occurrence of two or more endocrine gland tumors in a patient or related individuals in the same family. They are inherited in an autosomal dominant fashion and are highly penetrant. There are three types of MEN syndromes: MEN type 1 (MEN1), MEN type 2 (MEN2), and MEN type 4 (MEN4). MEN2 is further divided into MEN2A, MEN2B (formerly known MEN3), and familial medullary thyroid carcinoma (FMTC). Although MEN syndromes are rare, it is crucial to identify individuals at risk for potentially life-threatening neoplasias. This review article provides an update on each MEN syndrome, its genetics, diagnosis, and management in children.
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Inoue C, Nishihama K, Hayasaki A, Okano Y, Hayashi A, Eguchi K, Uemura M, Suzuki T, Yasuma T, Inoue T, Yorifuji T, Mizuno S, Gabazza EC, Yano Y. Case Report: A Difficult-to-Diagnose Case of Hyperinsulinemic Hypoglycemia Surgically Treated After Developing Acute Pancreatitis. Front Endocrinol (Lausanne) 2021; 12:731071. [PMID: 34777243 PMCID: PMC8578890 DOI: 10.3389/fendo.2021.731071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/04/2021] [Indexed: 11/27/2022] Open
Abstract
The patient is a 28-year-old Japanese man diagnosed with severe congenital hyperinsulinemic-hypoglycemia six months after birth. Clinical records revealed no imaging evidence of pancreatic tumor at the time of diagnosis. Subsequently, he had developmental disorders and epilepsy caused by recurrent hypoglycemic attacks. The patient's hypoglycemia improved with oral diazoxide. However, he developed necrotizing acute pancreatitis at 28 years of age, thought to be due to diazoxide. Discontinuation of diazoxide caused persistent hypoglycemia, requiring continuous glucose supplementation by tube feeding and total parenteral nutrition. A selective arterial secretagogue injection test revealed diffuse pancreatic hypersecretion of insulin. He underwent subtotal distal (72%) pancreatectomy and splenectomy. There was no intraoperative visible pancreatic tumor. His hypoglycemia improved after the surgical procedure. The histopathological study revealed a high density of islets of Langerhans in the pancreatic body and tail. There were large islets of Langerhans and multiple neuroendocrine cell nests in the whole pancreas. Nests of neuroendocrine cells were also detected in lymph nodes. The pathological diagnosis was grade 1 neuroendocrine tumor (microinsulinomas) with lymph node metastases. This patient is a difficult-to-diagnose case of hyperinsulinemic hypoglycemia surgically treated after developing acute pancreatitis. We believe this is a unique case of microinsulinomas with lymph metastases diagnosed and treated as congenital hyperinsulinemic hypoglycemia for almost 28 years.
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Affiliation(s)
- Chisa Inoue
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kota Nishihama
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yuko Okano
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akinobu Hayashi
- Department of Pathology, Mie University Hospital, Tsu, Japan
| | - Kazuhito Eguchi
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mei Uemura
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Toshinari Suzuki
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taro Yasuma
- Department of Immunology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takeshi Inoue
- Department of Pathology, Osaka City General Hospital, Osaka, Japan
| | - Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children’s Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Esteban C. Gabazza
- Department of Immunology, Mie University Graduate School of Medicine, Tsu, Japan
- *Correspondence: Esteban C. Gabazza,
| | - Yutaka Yano
- Department of Diabetes, Metabolism, and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
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