1
|
Li C, Juliana CA, Yuan Y, Li M, Lu M, Chen P, Boodhansingh KE, Doliba NM, Bhatti TR, Adzick NS, Stanley CA, De León DD. Phenotypic Characterization of Congenital Hyperinsulinism Due to Novel Activating Glucokinase Mutations. Diabetes 2023; 72:1809-1819. [PMID: 37725835 PMCID: PMC10658072 DOI: 10.2337/db23-0465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/10/2023] [Indexed: 09/21/2023]
Abstract
The importance of glucokinase (GK) in the regulation of insulin secretion has been highlighted by the phenotypes of individuals with activating and inactivating mutations in the glucokinase gene (GCK). Here we report 10 individuals with congenital hyperinsulinism (HI) caused by eight unique activating mutations of GCK. Six are novel and located near previously identified activating mutations sites. The first recognized episode of hypoglycemia in these patients occurred between birth and 24 years, and the severity of the phenotype was also variable. Mutant enzymes were expressed and purified for enzyme kinetics in vitro. Mutant enzymes had low glucose half-saturation concentration values and an increased enzyme activity index compared with wild-type GK. We performed functional evaluation of islets from the pancreata of three children with GCK-HI who required pancreatectomy. Basal insulin secretion in perifused GCK-HI islets was normal, and the response to glyburide was preserved. However, the threshold for glucose-stimulated insulin secretion in perifused glucokinase hyperinsulinism (GCK-HI) islets was decreased, and glucagon secretion was greatly suppressed. Our evaluation of novel GCK disease-associated mutations revealed that the detrimental effects of these mutations on glucose homeostasis can be attributed not only to a lowering of the glucose threshold of insulin secretion but also to a decreased counterregulatory glucagon secretory response. ARTICLE HIGHLIGHTS Our evaluation of six novel and two previously published activating GCK mutations revealed that the detrimental effects of these mutations on glucose homeostasis can be attributed not only to a lowering of the glucose threshold of insulin secretion but also to a decreased counterregulatory glucagon secretory response. These studies provide insights into the pathophysiology of GCK-hyperinsulinism and the dual role of glucokinase in β-cells and α-cells to regulate glucose homeostasis.
Collapse
Affiliation(s)
- Changhong Li
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Nanjing AscendRare Pharmaceutical Technology Co., Nanjing, China
| | - Christine A. Juliana
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Yue Yuan
- Nanjing AscendRare Pharmaceutical Technology Co., Nanjing, China
| | - Ming Li
- Department of Endocrinology, National Health Commission (NHC) Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Lu
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Pan Chen
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kara E. Boodhansingh
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nicolai M. Doliba
- Institute of Diabetes, Obesity and Metabolism, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Tricia R. Bhatti
- Department of Pathology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N. Scott Adzick
- Department of Surgery, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Charles A. Stanley
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Diva D. De León
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
2
|
Loh WJ, Dacay LM, Tan CSH, Ang SF, Yap F, Lim SC, Khoo J. Glucokinase activating mutation causing hypoglycaemia diagnosed late in adult who fasts for Ramadhan. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210043. [PMID: 34184638 PMCID: PMC8240715 DOI: 10.1530/edm-21-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Activating mutation of glucokinase gene (GCK) causes resetting of insulin inhibition at a lower glucose threshold causing hyperinsulinaemic hypoglycaemia (GCK-HH). This is the first reported case who tolerated years of regular fasting during Ramadhan, presenting only with seizure and syncope now. We describe a case with GCK gene variant p.T65I diagnosed in a 51-year-old woman with hypoglycaemia unawareness even at glucose level of 1.6 mmol/L. Insulin and C-peptide levels during hypoglycaemia were suggestive of hyperinsulinism, but at a day after intravenous glucagon, hypoglycaemia occurred with low insulin and C-peptide levels, pointing against insulinoma as the underlying aetiology. Imaging studies of the pancreas and calcium arterial stimulation venous sampling were unremarkable. A review of old medical records revealed asymptomatic hypoglycaemia years ago. Genetic testing confirmed activating mutation of GCK. Hypoglycaemia was successfully controlled with a somatostatin analogue. This case highlights the importance of consideration of genetic causes of hypoglycaemia in adulthood, especially when imaging is uninformative. LEARNING POINTS Consider genetic causes of endogenous hyperinsulinism hypoglycaemia in adulthood, especially when imaging is uninformative. Late presentation of activating mutation of GCK can occur because of hypoglycaemia unawareness. Long-acting somatostatin analogue may be useful for the treatment of activating mutation of GCK causing hypoglycaemia. Depending on the glucose level when the blood was taken, and the threshold of glucose-stimulated insulin release (GSIR), the serum insulin and C-peptide levels may be raised (hyperinsulinaemic) or low (hypoinsulinaemic) in patients with activating mutation of GCK. Glucagon may be useful to hasten the process of unmasking the low insulin level during hypoglycaemia below the GSIR level of which insulin released is suppressed.
Collapse
Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Clara Si Hua Tan
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Fabian Yap
- Department of Paediatric Endocrinology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| |
Collapse
|
3
|
Drachmann D, Hoffmann E, Carrigg A, Davis-Yates B, Weaver V, Thornton P, Weinstein DA, Petersen JS, Shah P, Christesen HT. Towards enhanced understanding of idiopathic ketotic hypoglycemia: a literature review and introduction of the patient organization, Ketotic Hypoglycemia International. Orphanet J Rare Dis 2021; 16:173. [PMID: 33849624 PMCID: PMC8045369 DOI: 10.1186/s13023-021-01797-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic Ketotic hypoglycemia (IKH) is a diagnosis of exclusion. Although considered as the most frequent cause of hypoglycemia in childhood, little progress has been made to advance the understanding of IKH since the medical term was coined in 1964. We aimed to review the literature on ketotic hypoglycemia (KH) and introduce a novel patient organization, Ketotic Hypoglycemia International (KHI). RESULTS IKH may be diagnosed after the exclusion of various metabolic and hormonal diseases with KH. Although often mild and self-limiting, more severe and long-lasting IKH occurs. We therefore divide IKH in physiological KH and pathological KH, the latter defined as recurrent symptomatic, or occasionally symptomatic, episodes with beta-hydroxybutyrate ≥ 1.0 mmol/L and blood glucose < 70 mg/dL (3.9 mol/L), in the absence of prolonged fasting, acute infections and chronic diseases known to cause KH. Pathological KH may represent undiscovered diseases, e.g. glycogen storage disease IXa, Silver-Russel syndrome, and ketone transporter defects, or suggested novel disease entities identified by exome sequencing. The management of KH aims to prevent hypoglycemia, fatty acid oxidation and protein deficiency by supplying adequate amounts of carbohydrates and protein, including nutritional therapy, uncooked cornstarch, and sometimes continuous tube feeding by night. Still, intravenous dextrose may be needed in acute KH episodes. Failure to acknowledge that IKH can be more than normal variation may lead to under-treatment. KHI is a non-profit, patient-centric, global organization established in 2020. The organization was created by adult IKH patients, patient family members, and volunteers. The mission of KHI is to enhance the understanding of IKH while advocating for patients, their families and the continued research into KH. CONCLUSION IKH is a heterogeneous disorder including physiological KH and pathological KH. IKH may represent missed diagnoses or novel disease entities, but shares common management principles to prevent fatty acid oxygenation. KHI, a novel patient organization, aims to enhance the understanding of IKH by supporting IKH families and research into IKH.
Collapse
Affiliation(s)
| | - Erica Hoffmann
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Austin Carrigg
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Beccie Davis-Yates
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark.,School of Social Science, Nottingham Institute of Education, Nottingham, UK
| | - Valerie Weaver
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | | | - David A Weinstein
- Glycogen Storage Disease Program, University of Connecticut, Farmington, CT, USA
| | | | - Pratik Shah
- Endocrinology Department, The Royal London Children's Hospital, Barts Health NHS Trust and Queen Mary University London, London, UK
| | - Henrik Thybo Christesen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Hans Christian Andersen Children's Hospital and Steno Diabetes Centre Odense, Odense University Hospital, JB Windsloews Vej 4, 5000, Odense C, Denmark.
| |
Collapse
|
4
|
Haris B, Saraswathi S, Hussain K. Somatostatin analogues for the treatment of hyperinsulinaemic hypoglycaemia. Ther Adv Endocrinol Metab 2020; 11:2042018820965068. [PMID: 33329885 PMCID: PMC7720331 DOI: 10.1177/2042018820965068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a biochemical finding of low blood glucose levels due to the dysregulation of insulin secretion from pancreatic β-cells. Under normal physiological conditions, glucose metabolism is coupled to β-cell insulin secretion so that blood glucose levels are maintained within the physiological range of 3.5-5.5 mmol/L. However, in HH this coupling of glucose metabolism to insulin secretion is perturbed so that insulin secretion becomes unregulated. HH typically occurs in the neonatal, infancy and childhood periods and can be due to many different causes. Adults can also present with HH but the causes in adults tend to be different. Somatostatin (SST) is a peptide hormone that is released by the delta cells (δ-cells) in the pancreas. It binds to G protein-coupled SST receptors to regulate a variety of location-specific and selective functions such as hormone inhibition, neurotransmission and cell proliferation. SST plays a potent role in the regulation of both insulin and glucagon secretion in response to changes in glucose levels by negative feedback mechanism. The half-life of SST is only 1-3 min due to quick degradation by peptidases in plasma and tissues. Thus, a direct continuous intravenous or subcutaneous infusion is required to achieve the therapeutic effect. These limitations prompted the discovery of SST analogues such as octreotide and lanreotide, which have longer half-lives and therefore can be administered as injections. SST analogues are used to treat different forms of HH in children and adults and therapeutic effect is achieved by suppressing insulin secretion from pancreatic β-cells by complex mechanisms. These treatments are associated with several side effects, especially in the newborn period, with necrotizing enterocolitis being the most serious side effect and hence SS analogues should be used with extreme caution in this age group.
Collapse
Affiliation(s)
- Basma Haris
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Saras Saraswathi
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Professor of Paediatrics, Weill Cornell Medicine-Qatar, Division Chief – Endocrinology, Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, OPC, C6-340 |PO Box 26999, Al Luqta Street, Education City North Campus, Doha, Qatar
| |
Collapse
|
5
|
Douillard C, Jannin A, Vantyghem MC. Rare causes of hypoglycemia in adults. ANNALES D'ENDOCRINOLOGIE 2020; 81:110-117. [PMID: 32409005 DOI: 10.1016/j.ando.2020.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022]
Abstract
Hypoglycemia is defined by a low blood glucose level associated to clinical symptoms. Hypoglycemia may be related to treatment of diabetes, but also to drugs, alcohol, critical illness, cortisol insufficiency including hypopituitarism, insulinoma, bariatric or gastric surgery, pancreas transplantation or glucagon deficiency, or may be surreptitious. Some hypoglycemic episodes remain unexplained, and genetic, paraneoplastic and immune causes should be considered. Genetic causes may be related to endogenous hyperinsulinism and to inborn errors of metabolism (IEM). Endogenous hyperinsulinism is related to monogenic congenital hyperinsulinism, and especially to mutations of the glucokinase-activating gene or of insulin receptors, both characterised by postprandial hypoglycemia with major hyperinsulinism. In adulthood, IEM-related hypoglycemia can persist in a previously diagnosed childhood disease or may be a presenting sign. It is suggested by systemic involvement (rhabdomyolysis after fasting or exercising, heart disease, hepatomegaly), sometimes associated to a family history of hypoglycemia. The timing of hypoglycemic episodes with respect to the last meal also helps to orientate diagnosis. Fasting hypoglycemia may be related to type 0, I or III glycogen synthesis disorder, fatty acid oxidation or gluconeogenesis disorder. Postprandial hypoglycemia may be related to inherited fructose intolerance. Exercise-induced hyperinsulinism is mainly related to activating mutation of the SLC16A1 gene. Besides exceptional ectopic insulin secretion, paraneoplastic causes involve NICTH (Non-Islet-Cell Tumour Hypoglycemia), caused by Big-IGF2 secretion by a large tumour, with low blood levels of insulin, C-peptide and IGF1. Autoimmune causes involve antibodies against insulin (HIRATA syndrome), especially in case of Graves' disease, or against the insulin receptor. Medical history, timing, and insulin level orientate the diagnosis.
Collapse
Affiliation(s)
- Claire Douillard
- Endocrinology, diabetology, metabolism department, Lille university hospital, Lille, France; Lille reference centre of inborn errors of metabolism, Lille, France.
| | - Arnaud Jannin
- Endocrinology, diabetology, metabolism department, Lille university hospital, Lille, France.
| | - Marie-Christine Vantyghem
- Endocrinology, diabetology, metabolism department, Lille university hospital, Lille, France; Inserm U1190 translational research in diabetes, Lille, France; European genomic institute for diabetes EGID, Lille, France.
| |
Collapse
|
6
|
Challis BG, Powlson AS, Casey RT, Pearson C, Lam BY, Ma M, Pitfield D, Yeo GSH, Godfrey E, Cheow HK, Chatterjee VK, Carroll NR, Shaw A, Buscombe JR, Simpson HL. Adult-onset hyperinsulinaemic hypoglycaemia in clinical practice: diagnosis, aetiology and management. Endocr Connect 2017; 6:540-548. [PMID: 28784625 PMCID: PMC5597976 DOI: 10.1530/ec-17-0076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/07/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE In adults with hyperinsulinaemic hypoglycaemia (HH), in particular those with insulinoma, the optimal diagnostic and management strategies remain uncertain. Here, we sought to characterise the biochemical and radiological assessment, and clinical management of adults with HH at a tertiary centre over a thirteen-year period. DESIGN Clinical, biochemical, radiological and histological data were reviewed from all confirmed cases of adult-onset hyperinsulinaemic hypoglycaemia at our centre between 2003 and 2016. In a subset of patients with stage I insulinoma, whole-exome sequencing of tumour DNA was performed. RESULTS Twenty-nine patients were identified (27 insulinoma, including 6 subjects with metastatic disease; 1 pro-insulin/GLP-1 co-secreting tumour; 1 activating glucokinase mutation). In all cases, hypoglycaemia (glucose ≤2.2 mmol/L) was achieved within 48 h of a supervised fast. At fast termination, subjects with stage IV insulinoma had significantly higher insulin, C-peptide and pro-insulin compared to those with insulinoma staged I-IIIB. Preoperative localisation of insulinoma was most successfully achieved with EUS. In two patients with inoperable, metastatic insulinoma, peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTATATE rapidly restored euglycaemia and lowered fasting insulin. Finally, in a subset of stage I insulinoma, whole-exome sequencing of tumour DNA identified the pathogenic Ying Yang-1 (YY1) somatic mutation (c.C1115G/p.T372R) in one tumour, with all tumours exhibiting a low somatic mutation burden. CONCLUSION Our study highlights, in particular, the utility of the 48-h fast in the diagnosis of insulinoma, EUS for tumour localisation and the value of PRRT therapy in the treatment of metastatic disease.
Collapse
Affiliation(s)
- Benjamin G Challis
- Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
- Wolfson Diabetes and Endocrine CentreAddenbrooke's Hospital, Cambridge, UK
- IMED Biotech UnitClinical Discovery Unit, AstraZeneca, UK
| | - Andrew S Powlson
- Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
- Wolfson Diabetes and Endocrine CentreAddenbrooke's Hospital, Cambridge, UK
| | - Ruth T Casey
- Wolfson Diabetes and Endocrine CentreAddenbrooke's Hospital, Cambridge, UK
| | - Carla Pearson
- Wolfson Diabetes and Endocrine CentreAddenbrooke's Hospital, Cambridge, UK
| | - Brian Y Lam
- Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Marcella Ma
- Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Deborah Pitfield
- Wolfson Diabetes and Endocrine CentreAddenbrooke's Hospital, Cambridge, UK
| | - Giles S H Yeo
- Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Edmund Godfrey
- Department of RadiologyAddenbrooke's Hospital, Cambridge, UK
| | - Heok K Cheow
- Department of RadiologyAddenbrooke's Hospital, Cambridge, UK
- Department of Nuclear MedicineAddenbrooke's Hospital, Cambridge, UK
| | - V Krishna Chatterjee
- Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
- Wolfson Diabetes and Endocrine CentreAddenbrooke's Hospital, Cambridge, UK
| | | | - Ashley Shaw
- Department of RadiologyAddenbrooke's Hospital, Cambridge, UK
| | - John R Buscombe
- Department of RadiologyAddenbrooke's Hospital, Cambridge, UK
- Department of Nuclear MedicineAddenbrooke's Hospital, Cambridge, UK
| | - Helen L Simpson
- Department of Diabetes and EndocrinologyUCLH NHS Foundation Trust, London, UK
| |
Collapse
|
7
|
Geilswijk M, Andersen LL, Frost M, Brusgaard K, Beck-Nielsen H, Frederiksen AL, Jensen DM. Octreotide therapy and restricted fetal growth: pregnancy in familial hyperinsulinemic hypoglycemia. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM160126. [PMID: 28458896 PMCID: PMC5404468 DOI: 10.1530/edm-16-0126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/13/2017] [Indexed: 12/30/2022] Open
Abstract
SUMMARY Hypoglycemia during pregnancy can have serious health implications for both mother and fetus. Although not generally recommended in pregnancy, synthetic somatostatin analogues are used for the management of blood glucose levels in expectant hyperinsulinemic mothers. Recent reports suggest that octreotide treatment in pregnancy, as well as hypoglycemia in itself, may pose a risk of fetal growth restriction. During pregnancy, management of blood glucose levels in familial hyperinsulinemic hypoglycemia thus forms a medical dilemma. We report on pregnancy outcomes in a woman with symptomatic familial hyperinsulinemic hypoglycemia, type 3. During the patient's first pregnancy with a viable fetus octreotide treatment was instituted in gestational age 23 weeks to prevent severe hypoglycemic incidences. Fetal growth velocity declined, and at 37 weeks of gestation, intrauterine growth retardation was evident. During the second pregnancy with a viable fetus, blood glucose levels were managed through dietary intervention alone. Thus, the patient was advised to take small but frequent meals high in fiber and low in carbohydrates. Throughout pregnancy, no incidences of severe hypoglycemia occurred and fetal growth velocity was normal. We conclude that octreotide treatment during pregnancy may pose a risk of fetal growth restriction and warrants careful consideration. In some cases of familial hyperinsulinemic hypoglycemia, blood glucose levels can be successfully managed through diet only, also during pregnancy. LEARNING POINTS Gain-of-function mutations in GCK cause familial hyperinsulinemic hypoglycemia.Hypoglycemia during pregnancy may have serious health implications for mother and fetus.Pregnancy with hyperinsulinism represents a medical dilemma as hypoglycemia as well as octreotide treatment may pose a risk of fetal growth restriction.In some cases of familial hyperinsulinemic hypoglycemia, blood glucose levels can be successfully managed through diet only.
Collapse
Affiliation(s)
| | - Lise Lotte Andersen
- Departments of Obstetrics.,Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Morten Frost
- Departments of Endocrinology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Klaus Brusgaard
- Departments of Clinical Genetics.,Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Henning Beck-Nielsen
- Departments of Endocrinology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Anja Lisbeth Frederiksen
- Departments of Clinical Genetics.,Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Dorte Møller Jensen
- Departments of Obstetrics.,Departments of Endocrinology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
8
|
99mTc Labeled Glucagon-Like Peptide-1-Analogue (99mTc-GLP1) Scintigraphy in the Management of Patients with Occult Insulinoma. PLoS One 2016; 11:e0160714. [PMID: 27526057 PMCID: PMC4985165 DOI: 10.1371/journal.pone.0160714] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/22/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to assess the utility of [Lys40(Ahx-HYNIC-99mTc/EDDA)NH2]-exendin-4 scintigraphy in the management of patients with hypoglycemia, particularly in the detection of occult insulinoma. MATERIALS AND METHODS Forty patients with hypoglycemia and increased/confusing results of serum insulin and C-peptide concentration and negative/inconclusive results of other imaging examinations were enrolled in the study. In all patients GLP-1 receptor imaging was performed to localise potential pancreatic lesions. RESULTS Positive results of GLP-1 scintigraphy were observed in 28 patients. In 18 patients postsurgical histopathological examination confirmed diagnosis of insulinoma. Two patients had contraindications to the surgery, one patient did not want to be operated. One patient, who presented with postprandial hypoglycemia, with positive result of GLP-1 imaging was not qualified for surgery and is in the observational group. Eight patients were lost for follow up, among them 6 patients with positive GLP-1 scintigraphy result. One patient with negative scintigraphy was diagnosed with malignant insulinoma. In two patients with negative scintigraphy Munchausen syndrome was diagnosed (patients were taking insulin). Other seven patients with negative results of 99mTcGLP-1 scintigraphy and postprandial hypoglycemia with C-peptide and insulin levels within the limits of normal ranges are in the observational group. We would like to mention that 99mTc-GLP1-SPECT/CT was also performed in 3 pts with nesidioblastosis (revealing diffuse tracer uptake in two and a focal lesion in one case) and in two patients with malignant insulinoma (with the a focal uptake in the localization of a removed pancreatic headin one case and negative GLP-1 1 scintigraphy in the other patient). CONCLUSIONS 99mTc-GLP1-SPECT/CT could be helpful examination in the management of patients with hypoglycemia enabling proper localization of the pancreatic lesion and effective surgical treatment. This imaging technique may eliminate the need to perform invasive procedures in case of occult insulinoma.
Collapse
|
9
|
Challis BG, Harris J, Sleigh A, Isaac I, Orme SM, Seevaratnam N, Dhatariya K, Simpson HL, Semple RK. Familial adult onset hyperinsulinism due to an activating glucokinase mutation: implications for pharmacological glucokinase activation. Clin Endocrinol (Oxf) 2014; 81:855-61. [PMID: 24890200 PMCID: PMC4735948 DOI: 10.1111/cen.12517] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/11/2014] [Accepted: 05/27/2014] [Indexed: 01/13/2023]
Abstract
CONTEXT Glucokinase (GCK) phosphorylates and thereby "traps" glucose in cells, thus serving as a gatekeeper for cellular glucose metabolism, particularly in hepatocytes and pancreatic beta cells. In humans, activating GCK mutations cause familial hyperinsulinaemic hypoglycaemia (GCK-HH), leading to keen interest in the potential of small-molecule glucokinase activators (GKAs) as treatments for diabetes mellitus. Many such agents have been developed; however, observation of side effects including hypertriglyceridaemia and hepatic steatosis has delayed their clinical development. OBJECTIVE To describe the clinical presentation and metabolic profiles of affected family members in a kindred with familial hyperinsulinism of adult presentation due to a known activating mutation in GCK. DESIGN Clinical, biochemical and metabolic assessment, and GCK sequencing in affected family members. RESULTS In the 60-year-old female proband, hyperinsulinaemic hypoglycaemia (blood glucose 2·1 mmol/mol, insulin 18 pm) was confirmed following 34 h of fasting; however, abdominal computed tomography (CT), pancreatic MRI, endoscopic ultrasound, octreotide scintigraphy and selective arterial calcium stimulation failed to localize an insulinoma. A prolonged OGTT revealed fasting hypoglycaemia that was exacerbated after glucose challenge, consistent with dysregulated glucose-stimulated insulin release. A heterozygous activating mutation, p.Val389Leu, in the glucokinase gene (GCK) was found in the proband and four other family members. Of these, two had been investigated elsewhere for recurrent hypoglycaemia in adulthood, while the other two adult relatives were asymptomatic despite profound hypoglycaemia. All three of the available family members with the p.Val389Leu mutation had normal serum lipid profiles, normal rates of fasting hepatic de novo lipogenesis and had hepatic triglyceride levels commensurate with their degree of adiposity. CONCLUSION Activating GCK mutations may present in late adulthood with hyperinsulinaemic hypoglycaemia and should be considered even in older patients being investigated for insulinoma. Normal circulating lipids, rates of hepatic de novo lipogenesis and appropriate hepatic triglyceride content for degree of adiposity in the patients we describe suggest that even lifelong GCK activation in isolation is insufficient to produce fatty liver and metabolic dyslipidaemia.
Collapse
Affiliation(s)
- Benjamin G Challis
- University of Cambridge Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Agin A, Charrie A, Chikh K, Tabarin A, Vezzosi D. Fast test: Clinical practice and interpretation. ANNALES D'ENDOCRINOLOGIE 2013; 74:174-84. [DOI: 10.1016/j.ando.2013.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
11
|
Douillard C, Mention K, Dobbelaere D, Wemeau JL, Saudubray JM, Vantyghem MC. Hypoglycaemia related to inherited metabolic diseases in adults. Orphanet J Rare Dis 2012; 7:26. [PMID: 22587661 PMCID: PMC3458880 DOI: 10.1186/1750-1172-7-26] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 03/19/2012] [Indexed: 12/15/2022] Open
Abstract
In non-diabetic adult patients, hypoglycaemia may be related to drugs, critical illness, cortisol or glucagon insufficiency, non-islet cell tumour, insulinoma, or it may be surreptitious. Nevertheless, some hypoglycaemic episodes remain unexplained, and inborn errors of metabolism (IEM) should be considered, particularly in cases of multisystemic involvement. In children, IEM are considered a differential diagnosis in cases of hypoglycaemia. In adulthood, IEM-related hypoglycaemia can persist in a previously diagnosed childhood disease. Hypoglycaemia may sometimes be a presenting sign of the IEM. Short stature, hepatomegaly, hypogonadism, dysmorphia or muscular symptoms are signs suggestive of IEM-related hypoglycaemia. In both adults and children, hypoglycaemia can be clinically classified according to its timing. Postprandial hypoglycaemia can be an indicator of either endogenous hyperinsulinism linked to non-insulinoma pancreatogenic hypoglycaemia syndrome (NIPHS, unknown incidence in adults) or very rarely, inherited fructose intolerance. Glucokinase-activating mutations (one family) are the only genetic disorder responsible for NIPH in adults that has been clearly identified so far. Exercise-induced hyperinsulinism is linked to an activating mutation of the monocarboxylate transporter 1 (one family). Fasting hypoglycaemia may be caused by IEM that were already diagnosed in childhood and persist into adulthood: glycogen storage disease (GSD) type I, III, 0, VI and IX; glucose transporter 2 deficiency; fatty acid oxidation; ketogenesis disorders; and gluconeogenesis disorders. Fasting hypoglycaemia in adulthood can also be a rare presenting sign of an IEM, especially in GSD type III, fatty acid oxidation [medium-chain acyl-CoA dehydrogenase (MCAD), ketogenesis disorders (3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) lyase deficiency, and gluconeogenesis disorders (fructose-1,6-biphosphatase deficiency)].
Collapse
Affiliation(s)
- Claire Douillard
- Service d'Endocrinologie et maladies Métaboliques, Hôpital Claude Huriez, Centre Hospitalier Régional et Universitaire de Lille, France.
| | | | | | | | | | | |
Collapse
|
12
|
Christesen HT, Brusgaard K, Hussain K. Recurrent spontaneous hypoglycaemia causes loss of neurogenic and neuroglycopaenic signs in infants with congenital hyperinsulinism. Clin Endocrinol (Oxf) 2012; 76:548-54. [PMID: 21981106 DOI: 10.1111/j.1365-2265.2011.04250.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hypoglycaemia-associated autonomic failure (HAAF) with impaired neurogenic and neuroglycopaenic responses occurs in adults following recent, repeated hypoglycaemia. We aimed to evaluate whether HAAF also occurs in patients with infant-onset congenital hyperinsulinism (CHI). DESIGN, PATIENTS A controlled fast was performed in (i) seven CHI infants with initial symptomatic hypoglycaemia and three recent episodes of spontaneous recurrent hypoglycaemia each lasting <5 min and in (ii) seven infants with idiopathic ketotic hypoglycaemia for control. MEASUREMENTS At the time of hypoglycaemia (blood glucose <3 mmol/l or clinical signs), blood was drawn for serum insulin, cortisol, glucagon, adrenalin and nor-adrenalin. Signs of hypoglycaemia were documented. In CHI patients, the ABCC8 and KCNJ11 genes were analysed by denaturing high performance liquid chromatography (DHPLC) and/or direct bidirectional sequencing. RESULTS Two CHI patients had a paternal ABCC8 mutation, five had no mutations. When repeated hypoglycaemia was provoked, all CHI patients exhibited a complete loss of clinical signs of hypoglycaemia, along with a global blunting of the counter-regulatory hormones cortisol, glucagon, growth hormone, adrenalin and nor-adrenalin responses (median values 256 nmol/l, 23 pmol/l, 5·6 mU/l, 390 pmol/l and 2·9 nmol/l, respectively), irrespective of mutational status. In the controls, hypoglycaemia was always clinically overt with normal counter-regulatory cortisol, glucagon, adrenalin and nor-adrenalin responses (530 nmol/l, 60, 920 pmol/l and 4·0 nmol/l, respectively). CONCLUSION Recurrent hyperinsulinaemic hypoglycaemia even of short duration blunts the autonomic, neuroglycopaenic and glucose counter-regulatory hormonal responses in patients with infant-onset CHI resulting in clinically silent hypoglycaemia. Tight, or continuous, glucose monitoring is therefore recommended, especially in conservatively treated patients.
Collapse
|
13
|
Hussain K. Mutations in pancreatic ß-cell Glucokinase as a cause of hyperinsulinaemic hypoglycaemia and neonatal diabetes mellitus. Rev Endocr Metab Disord 2010; 11:179-83. [PMID: 20878480 DOI: 10.1007/s11154-010-9147-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Glucokinase is a key enzyme involved in regulating insulin secretion from the pancreatic ß-cell. The unique role of glucokinase in human glucose physiology is illustrated by the fact that genetic mutations in glucokinase can either cause hyperglycaemia or hypoglycaemia. Heterozygous inactivating mutations in glucokinase cause maturity-onset diabetes of the young (MODY), homozygous inactivating in glucokinase mutations result in permanent neonatal diabetes whereas heterozygous activating glucokinase mutations cause hyperinsulinaemic hypoglycaemia.
Collapse
Affiliation(s)
- Khalid Hussain
- Clinical and Molecular Genetics Unit, The Developmental Endocrinology Research Group, Institute of Child Health, Hospital for Children NHS Trust, University College London, Great Ormond Street, London, UK.
| |
Collapse
|
14
|
Abstract
Insulinomas are rare causes of hypoglycemia. After having ruled out non insulinomatous causes of hypoglycemia in a patient in whom Whipple's triad is documented, hyperinsulinism must be demonstrated biochemically, either during a spontaneous hypoglycemic episode or, more often, during a supervised fast which may be prolonged up to 72 h. A mixed-meal test may also help to diagnose the very rare cases of postprandial hypoglycemia related to non insulinoma pancreatogenic hypoglycemic syndrome (NIPHS) or to some rare insulinomas. Only when diagnosis of hypoglycemic hyperinsulinism is made, the tumor localization process may be initiated. This may be difficult due to the small size of insulinomas (generally < 1 cm). Multimodal approach is necessary. The association of endoscopic ultrasound and CT-scan or MRI seems optimal. Octreoscan will be also performed. First results with a very new technique, the GLP-1 receptor imaging, are promising for localizing very small tumors. This localization aims to allow a sparing surgery; enucleation of benign tumors, if possible, allows a pancreatic tissue preservation in patients with quite normal survival.
Collapse
Affiliation(s)
- L Cazabat
- Hôpitaux de Paris, Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre et Faculté de Médicine Paris-Sud, Université Paris Sud 11, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France.
| | | |
Collapse
|
15
|
Ahn J, Lee SE, Lee ES, Chung YJ, Oh YS, Shinn SH, Kim J. A case of nesidioblastosis causing hypoglycaemia after delivery. Diabetes Res Clin Pract 2009; 83:e5-7. [PMID: 19019477 DOI: 10.1016/j.diabres.2008.09.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Revised: 09/28/2008] [Accepted: 09/30/2008] [Indexed: 12/14/2022]
Abstract
Nesidioblastosis is a rare cause of adult-onset hyperinsulinaemic hypoglycaemia. We describe a case of nesidioblastosis during pregnancy in a woman receiving medical nutrition therapy for suspected gestational diabetes. However, nesidioblastosis was undiscovered until the development of hypoglycaemia after delivery, being previously masked by pregnancy-related changes in insulin sensitivity.
Collapse
Affiliation(s)
- Jihyun Ahn
- Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | | | | | | | | | | | | |
Collapse
|