Serum sickness-like reactions associated with type III insulin allergy responding to plasmapheresis

A case report and systematic literature review: insulin-induced type III hypersensitivity reaction

Insulin-induced type III hypersensitivity reactions (HSRs) are exceedingly rare and pose complex diagnostic and management challenges. We describe a case of a 43-year-old woman with type 1 diabetes mellitus (DM), severe insulin resistance, and subcutaneous nodules at injection sites, accompanied by elevated anti-insulin IgG autoantibodies. Treatment involved therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIg) as bridge therapy, followed by long-term immunosuppression, which reduced autoantibody levels and improved insulin tolerance. Given the limited treatment guidelines, we conducted a comprehensive literature review, identifying 16 similar cases. Most patients were females with a median age of 36.5 years; 63% had type 1 DM, and 44% had concurrent insulin resistance (56% with elevated autoantibodies). Treatment approaches varied, with glucocorticoids used in 67% of cases. Patients with type 1 DM were less responsive to steroids than those with type 2 DM, and had a more severe course. Of those patients with severe disease necessitating immunosuppression, 66% had poor responses or experienced relapses. The underlying mechanism of insulin-induced type III HSRs remains poorly understood. Immunosuppressive therapy reduces anti-insulin IgG autoantibodies, leading to short-term clinical improvement and improved insulin resistance, emphasizing their crucial role in the condition. However, the long-term efficacy of immunosuppression remains uncertain and necessitates continuous evaluation and further research.

Case Report: Insulin hypersensitivity in youth with type 1 diabetes

Objective

Immediate type I, type III, and delayed type IV hypersensitivity reactions to insulin are rare, but potentially serious complications of exogenous insulin administration required for the treatment of type 1 diabetes (T1D).

Methods

We present four cases of insulin hypersensitivity reactions occurring in youth with T1D and a literature review of this topic.

Results

Insulin hypersensitivity reactions included types I, III, and IV with presentations ranging from localized urticaria, erythematous nodules, and eczematous plaques to anaphylaxis with respiratory distress. Reactions occurred in youth with newly diagnosed T1D and in those with long-standing T1D who were using both injection and insulin pump therapy. Multidisciplinary care involving pediatric endocrinology and allergy/immunology utilizing trials of many adjunct therapies yielded minimal improvement. Despite the use of various treatments, including antihistamines, topical therapies, immunosuppressant medications, desensitization trials, and intravenous immune globulin, cutaneous reactions, elevated hemoglobin A1c levels, and negative effects on quality of life remain persistent challenges. One patient became one of the youngest pancreas transplant recipients in the world at age 12 years due to uncontrollable symptoms and intolerable adverse effects of attempted therapies.

Conclusion

Although rare, insulin hypersensitivity reactions negatively affect glycemic control and quality of life. These cases demonstrate the varying severity and presentation of insulin hypersensitivity reactions along with the limited success of various treatment approaches. Given the life-sustaining nature of insulin therapy, further studies are needed to better understand the underlying pathophysiology of insulin hypersensitivity and to develop targeted treatment approaches.

Serum Sickness-Like Reactions After Pneumococcal Vaccination

Serum sickness or serum sickness-like reactions (SSLRs) constitute a rare complication that manifests in individuals after receiving vaccinations. In this case report, we present a patient with typical symptoms of SSLRs after pneumococcal vaccination. The time course of this disease and our diagnostic process are documented in detail. The literature related to serum sickness and SSLRs is also reviewed.

Pediatric drug eruptions

Drug eruptions in children are common but in general less studied than their adult counterparts. Aside from having significant impact on the child's health and quality of life, these reactions can limit what medications the patient can receive in the future. Familiarity with pediatric drug eruptions is important for accurate diagnosis and to prevent future recurrence or ineffective therapy. Our current understanding of how drug reactions differ mechanistically between children and adults is poor. There are multiple factors that could be contributing to the differing incidence, presentation, and treatment modalities offered to pediatric versus adult patients. For many of these cutaneous drug reactions, the treatment regime is not standardized, being based primarily on case reports. Although not comprehensive, this review highlights common pediatric drug eruption patterns and discuss diagnostic mimickers. Five cutaneous adverse drug reactions in the pediatric population are presented: morbilliform (exanthematous) eruptions, urticarial eruptions, serum sickness-like reactions, fixed drug eruptions, and DRESS syndrome. Clinical features, diagnostic workup, and management are discussed with an emphasis on the pediatric population.

Serum sickness-like reaction after the treatment of cellulitis with amoxicillin/clavulanate

Serum sickness-like reaction is a rare disease presentation. We describe a case of a man aged 58 years who presented with acute-onset polyarthralgia, intense pruritus of hands and feet, fever to 39.5°C and leucocytosis to 17.2×10³/mm³ 5 days after completing a 10-day course of amoxicillin/clavulanate for the treatment of finger cellulitis. With history, symptoms, physical examination findings and reported cases in the literature of serum sickness-like reactions to amoxicillin, a clinical diagnosis of serum sickness-like reaction was made. The patient was treated with non-steroidal anti-inflammatories with improvement in symptoms by the time of discharge.

Hypersensitivity Reaction to Insulin Glargine and Insulin Detemir in a Pediatric Patient: A Case Report

Allergy to human insulin or its analogs is rare, but it is still a significant issue in current diabetes care. Allergic reactions can range from localized injection site reactions to generalized anaphylaxis, and they can be caused by excipients or the insulin molecules themselves. We presented a case of a 14-year-old male patient with generalized allergic reactions to insulin glargine and insulin detemir. The patient was successfully managed by being switched to a continuous subcutaneous insulin infusion with insulin aspart. Allergic reactions to insulin detemir and insulin glargine have both been well described, with insulin detemir allergy appearing to be more common. There are several potential mechanisms for insulin allergy, and immunologic characteristics vary among different insulin analogs. After confirming insulin allergy in practice, management involves treating symptoms and switching insulin preparations. This is the first documented case of allergies to both insulin glargine and insulin detemir in a pediatric patient. Exact mechanism of insulin allergy is unknown, and management strategies must be individualized for each patient.

Serum sickness after treatment with rabbit antithymocyte globulin in a heart transplant recipient with previous rabbit exposure

Antithymocyte globulin (ATG) is a preparation of polyclonal antibodies frequently used to treat acute cellular rejection in organ transplant recipients. Use of rabbit ATG has been associated with serum sickness in liver and kidney transplantation patients previously exposed to rabbits. Here, we report the case of a heart transplantation patient with a history of significant rabbit exposure who had developed migratory diffuse arthralgias 13 days after receiving ATG for acute cellular rejection. Laboratory findings included C-reactive protein elevation, depressed levels of C3 and C4 complement, and strongly positive titers against rabbit immunoglobulin G, all strongly suggestive of serum sickness. To our knowledge, this is the first report of delayed serum sickness related to rabbit ATG after prior rabbit exposure in an adult heart transplantation patient. Early recognition of the symptoms of serum sickness can lead to prompt and appropriate management.

Development of insulin allergy after bone marrow transplantation

BACKGROUND

Insulin allergy is a not uncommon condition even though human insulin and insulin analogues are widely used. However, the development of insulin allergy after bone marrow transplantation has not been reported.

CASE REPORT

A 44-year-old Japanese woman had aplastic anaemia and secondary haemochromatosis. She was diagnosed with having diabetes at age 32 years and had been treated with human insulin. At age 34 years, bone marrow transplantation was performed. One year later, a rash and urticaria appeared immediately after insulin injections. Intracutaneous tests were positive for both human insulins and analogues, whereas the test for protamine was negative. Furthermore, an IgE-radioallergosorbent test against insulin was positive. Thus, we diagnosed the patient with having an IgE-mediated type I allergy against insulin. Insulin therapy with insulin aspart, which showed the least skin reaction, was continued and the insulin allergy disappeared in 7 years.

CONCLUSIONS

This is the first description of insulin allergy after bone marrow transplantation. Our case underscores the effects of bone marrow cells on IgE-mediated type I allergy for insulin.

Allergic reactions to human insulin: a review of current knowledge and treatment options

Although the incidence of insulin allergy decreased after the introduction of recombinant human insulin preparations, it is still a major problem which may be life-threatening in some cases. In this article, we attempted to review current knowledge concerning allergic reactions to human insulin and discuss the available treatment options of insulin allergy.