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Teoli J, Chikh K, Jouini-Bouhamri R, Charriere S, Fabien N, Raverot V. When discordant insulin and C-peptide levels lead to a medical diagnosis in a patient with transient hypoglycemia: Varying degrees of interference of insulin-antibody complexes on three insulin immunoassays. Heliyon 2024; 10:e34009. [PMID: 39071705 PMCID: PMC11280251 DOI: 10.1016/j.heliyon.2024.e34009] [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: 12/13/2023] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/30/2024] Open
Abstract
Background Determining the cause of hypoglycemia partly relies on blood insulin and C-peptide assays. Although the pancreatic secretion of these peptides is equimolar, discrepancies in their concentrations may occur. Case presentation We report the case of a 73-year-old woman with type 2 diabetes mellitus (T2DM) and a history of gastric bypass. The T2DM was initially treated with insulin analogs, which were interrupted due to transient hypoglycemia episodes three years before hospitalization in our endocrinology department. During this hospitalization, the most common etiologies of hypoglycemia were excluded. Fasting insulin level was high (190 mIU/L, reference values (RV): 5-25) on Architect i2000 (an assay recognizing insulin analogs) despite normal blood C-peptide (4.5 μg/L, RV: 0.8-5.2) and slight hypoglycemia (4.5 mmol/L, RV: 4.6-6.1). Insulin level using the Elecsys assay (an assay with low sensitivity to insulin analogs) was very high (>1000 mIU/L, RV: 2.6-24.9). This pattern was observed on several samples, including some taken during a fasting test. Insulin level was only slightly increased using the Mercodia iso-insulin ELISA kit (an assay recognizing insulin analogs). These results excluded an exogenous insulin intake and were suggestive of an interference on insulin assays. To explore the latter possibility, free anti-insulin antibodies were measured and found strongly positive. The presence of interfering insulin-antibody complexes was further investigated using gel filtration chromatography, polyethylene glycol precipitation, and dilution test. Based on these findings, an insulin autoimmune syndrome (IAS) was suspected to cause the hypoglycemic episodes observed. Conclusion Although a discrepancy between blood insulin and C-peptide levels points to insulin analog intake, IAS should also be considered, particularly in a patient with transient hypoglycemia. IAS is characterized by the presence of insulin-antibody complexes, which can induce varying degrees of interference on insulin immunoassays and may lead to discordant insulin and C-peptide levels according to the insulin immunoassay used.
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Affiliation(s)
- Jordan Teoli
- Laboratoire de Biologie Médicale Multisites, Service de Biochimie et Biologie Moléculaire, UM Biologie Endocrinienne, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Bron, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Institut Cellule Souche et Cerveau (SBRI), Unité INSERM 1208, Centre de Recherche INSERM, Bron, France
| | - Karim Chikh
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire de biologie Médicale Multisites, Service de Biochimie et Biologie Moléculaire, UM Biologie Endocrinienne, Centre de Biologie et Pathologie Sud, Hospices Civils de Lyon, Pierre-Bénite, France
- Laboratoire CarMen, UMR INSERM U1060/INRAE U1397, Université Claude Bernard Lyon 1, Pierre Bénite, France
| | - Ryme Jouini-Bouhamri
- Fédération d'Endocrinologie, Maladies Métaboliques, Diabète, et Nutrition, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Sybil Charriere
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire CarMen, UMR INSERM U1060/INRAE U1397, Université Claude Bernard Lyon 1, Pierre Bénite, France
- Fédération d'Endocrinologie, Maladies Métaboliques, Diabète, et Nutrition, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Nicole Fabien
- Service d'immunologie, Centre de Biologie et Pathologie Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Véronique Raverot
- Laboratoire de Biologie Médicale Multisites, Service de Biochimie et Biologie Moléculaire, UM Biologie Endocrinienne, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Bron, France
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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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Jerkins T, Stockham K, Bell DSH. Exogenous Insulin Antibody Syndrome (EIAS) Presenting in an Elderly, Long-Term Patient with Type 1 Diabetes Mellitus that Resolved with Low-Cost Outpatient Therapy with Mycophenolate Mofetil and Regular Insulin by Pump. Diabetes Ther 2024; 15:1473-1481. [PMID: 38653902 PMCID: PMC11096292 DOI: 10.1007/s13300-024-01573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
Exogenous insulin antibody syndrome (EIAS) has until recently been a rarely described complication of exogenous insulin therapy. EIAS results not only in hyperglycemia, but also in hypoglycemia and occasionally in ketoacidosis (DKA). The incidence of EIAS is increasing probably due to an overall increase in autoimmunity associated with the coronavirus disease 2019 (Covid-19) epidemic resulting in increasing binding of insulin by antibodies. Herein, we describe a case of EIAS occurring in an elderly patient with longstanding type 1 diabetes mellitus (T1DM) who had progressive loss of glycemic control. It responded positively, as we have previously described, to oral mycophenolate mofetil and the use of soluble regular insulin delivered by continuous subcutaneous insulin infusion (CSII). Therefore, EIAS is an increasingly frequent cause of hyperglycemia with and without DKA, and hypoglycemia in subjects with T1DM. Once diagnosed, they can be treated with mycophenolate mofetil and soluble insulin in an outpatient setting, which will decrease the rate of hospitalization and lower the expense of therapy.
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Batra CM, Jain S, Kumar KP, Goyal M, Kachroo V, Takkar S, Yadav R. Spontaneous Hypoglycaemia due to Insulin Autoimmune Syndrome in Six Cases, Response to Steroid Therapy and Rituximab. Indian J Endocrinol Metab 2024; 28:295-301. [PMID: 39086578 PMCID: PMC11288520 DOI: 10.4103/ijem.ijem_378_23] [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: 09/26/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Dr. Hirata of Japan first described insulin autoimmune syndrome (IAS) in 1970. Seven hundred ninety-five cases of this rare syndrome have been reported from Japan and China and 29 from India. IAS has the following characteristic features 1) severe spontaneous attacks of hyperinsulinemic hypoglycaemia, 2) high total immunoreactive insulin levels, 3) elevated insulin autoantibody (IAA) titres, 4) no prior exposure to exogenous insulin, and 5) no pathological abnormalities of the pancreatic islet cells. Methods We treated six cases of IAS with high doses of prednisolone for 4-6 weeks and then gradually reduced the doses. Diagnosis of IAS was established by documenting Whipple's triad of symptoms and signs of hypoglycaemia, blood sugar <55 mg/dl, improvement of symptoms with dextrose infusion, inappropriately increased insulin levels >3 uU/ml, C-peptide levels >0.6 ng/ml, and increased titres of anti-insulin autoantibodies. Insulinoma and non-pancreatic tumours were ruled out by CECT (contrast-enhanced computerised tomography) or MRI (magnetic resonance imaging) of the abdomen and if necessary endoscopic ultrasonography and gallium 68 Dotanoc PET (positron enhanced tomography). Autoimmune screening and serum electrophoresis were done to rule out multiple myeloma. Monitoring of the patient's blood sugars was done by the laboratory, glucometer readings, and a freestyle libre glucose monitoring system. Results Remission of hypoglycaemic episodes, hyperglycaemic episodes, and marked reduction of serum insulin and insulin autoantibodies in four out of six patients with diet therapy and steroids. Two patients resistant to steroids were treated with rituximab successfully. Patient 6 developed serious complications of cytomegalovirus and Pneumocystis carnii after rituximab, which were treated successfully. Conclusion A careful history including recent infections, medications, and vaccinations provides vital clues in the evaluation. An increased awareness of IAS will prevent unnecessary and costly investigations and surgery. Although it is often self-remitting, steroids are contributory in severe cases. Immunosuppressives are used successfully in cases refractory to steroids. Continuous glucose monitoring system (CGMS), by freestyle libre glucose monitoring system, provided real-time blood sugar values, total time in hypoglycaemia, and total time in the range (TIR), which proved very valuable in managing IAS patients. Low CGMS values should be corroborated clinically and with laboratory or glucometer values.
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Affiliation(s)
- Chandar M. Batra
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Savita Jain
- Endocrinology Deep Hospital, Ludhiana, Punjab, India
| | - Kiran P. Kumar
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Monika Goyal
- Department of Endocrinology, Batra Hospital and Medical Research Centre, New Delhi, India
| | - Varsha Kachroo
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Simran Takkar
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Rini Yadav
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
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He D, Gong H, Pan J, Zhu F, Jiang X, Su H. Recurrent Non-islet Cell Tumor Hypoglycemia Secondary to Hepatocellular Carcinoma: Case Report and Literature Review. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:752-758. [PMID: 37798922 DOI: 10.1055/a-2170-1691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
RATIONALE Non-islet cell tumor hypoglycemia (NICTH) is a paraneoplastic syndrome caused by tumors other than insulinoma that is primarily due to excessive production of insulin-like growth factor-II (IGF-II). The prevalence of NICTH is likely underestimated because of a lack of clinical recognition. PATIENT CONCERNS A 41-year-old male with massive malignant liver tumors presented with recurrent severe hypoglycemia, weight loss, and liver cirrhosis. DIAGNOSIS NICTH related to IGF-II produced by hepatocellular carcinoma was diagnosed based on clinical symptoms, biochemical tests, and elevated IGF-II/IGF-I ratio. INTERVENTION Initial treatment with intravenous glucose and parenteral nutrition showed limited efficacy. Glucocorticoids and recombinant human growth hormone led to progressive improvement in blood glucose levels. OUTCOME Due to extensive tumor burden and liver failure, surgical resection was not feasible, and the patient ultimately succumbed to refractory hypoglycemia and passed away in two weeks. LESSONS Early recognition and diagnosis of NICTH are crucial in patients with recurrent hypoglycemia and large tumors. Surgical resection is the preferred treatment option, but supportive care and pharmacological interventions, such as glucocorticoids and growth hormone, can help manage refractory hypoglycemia. Further research is needed to explore novel treatment options, including anti-IGF-I and -IGF-II neutralizing antibodies.
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Affiliation(s)
- Dan He
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Hongpeng Gong
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Jie Pan
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Fangchao Zhu
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Xiaofen Jiang
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Huang Su
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
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Edem D, Maradana J, Majety P, Antony MA, Menon L. Persistent Insulin Autoimmune Syndrome in a Caucasian Male in the Absence of Triggers. Cureus 2024; 16:e58270. [PMID: 38623323 PMCID: PMC11016734 DOI: 10.7759/cureus.58270] [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: 04/14/2024] [Indexed: 04/17/2024] Open
Abstract
Insulin autoimmune syndrome (IAS) or Hirata disease is a rare condition presenting as recurrent hypoglycemia, and associated with elevated insulin levels in the presence of insulin autoantibodies (IAAs) in patients who were never exposed to exogenous insulin and with no evidence of pancreatic abnormalities. IAS is much more frequent in East Asians, especially the Japanese population, compared to the lower incidence in Caucasians. However, it can be associated with other autoimmune diseases or drug use like methimazole and alpha-lipoic acid (ALA). We report a case of a 47-year-old Caucasian male presenting with a 12-month history of worsening episodes of fasting and post-prandial hypoglycemia associated with symptoms of dizziness, tremors, palpitations, and unconsciousness associated with hypoglycemia. Symptoms resolved with the administration of carbohydrate-containing foods, establishing Whipple's triad. At an outside facility, he had initial labs that showed elevated insulin levels (141 µU/ml) with normal glucose, C-peptide, and proinsulin levels, but there was no availability of an IAA lab assay. Given his symptoms, severity, and frequency of hypoglycemia, he was admitted to the hospital for a 72-hour fast, which showed the lowest glucose level of 64 mg/dl with inappropriately high insulin of 22.2 µU/ml, low C-peptide of 0.57 ng/ml, and undetectable proinsulin of <1.6 pmol/L, but with IAA being >50 U/ml (0.0-0.4 U/ml). He was treated with intensive dietary counseling with a low-carbohydrate diet and prednisone 20 mg twice daily initially. Additionally, he could not tolerate octreotide, diazoxide, and acarbose due to side effects. He is currently on prednisone 10 mg daily and nifedipine with no further hypoglycemic episodes, but still has a high IAA of >50 U/ml and serum insulin levels of 70-112 µU/ml. Our case highlights the importance of recognizing hypoglycemia and checking for IAA levels as first-line diagnostic tests, in the absence of which there could be a delay in diagnosis and leading to unnecessary lab and imaging testing. Our case is unique since it happened in a Caucasian without any prior exposure to a triggering factor and has not undergone self-remission yet, which happens in most of IAS cases.
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Affiliation(s)
- Dinesh Edem
- Endocrinology, Diabetes and Metabolism, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Jhansi Maradana
- Endocrinology, Diabetes and Metabolism, Mass General Brigham Wentworth-Douglas Hospital, Dover, USA
| | - Priyanka Majety
- Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, USA
| | - Mc Anto Antony
- Endocrinology, Diabetes and Metabolism, Medical University of South Carolina, Anderson, USA
| | - Lakshmi Menon
- Endocrinology, Diabetes and Metabolism, University of Arkansas for Medical Sciences, Little Rock, USA
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Xu LL, Chen JX, Cheng JP, Luo N. Exogenous insulin autoimmune syndrome: A case report and review of literature. World J Clin Cases 2024; 12:1691-1697. [PMID: 38576740 PMCID: PMC10989436 DOI: 10.12998/wjcc.v12.i9.1691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/23/2024] [Accepted: 03/06/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a severe manifestation of spontaneous hypoglycemia. It is characterized by elevated levels of immune-reactive insulin and highly potent insulin autoantibodies (IAAs), which are induced by endogenous insulin circulating in the bloodstream. It is distinguished by recurring instances of spontaneous hypoglycemia, the presence of IAA within the body, a substantial elevation in serum insulin levels, and an absence of prior exogenous insulin administration. Nevertheless, recent studies show that both conventional insulin and its analogs can induce IAS episodes, giving rise to the notion of non-classical IAS. Therefore, more attention should be paid to these diseases. CASE SUMMARY In this case report, we present a rare case of non-classical IAS in an 83-year-old male patient who present with symptoms of a psychiatric disorder. Upon symptom onset, the patient exhibited Whipple's triad (including hypoglycemia, blood glucose level less than 2.8 mmol/L during onset, and rapid relief of hypoglycemic symptoms after glucose administration). Concurrently, his serum insulin level was significantly elevated, which contradicted his C-peptide levels. After a comprehensive examination, the patient was diagnosed with exogenous insulin autoimmune syndrome. Considering that the patient had type 2 diabetes mellitus and a history of exogenous insulin use before disease onset, it was presumed that non classical IAS was induced by this condition. The PubMed database was used to search for previous cases of IAS and non-classical IAS to analyze their characteristics and treatment approaches. CONCLUSION The occurrence of non-classical IAS is associated with exogenous insulin or its analogs, as well as with sulfhydryl drugs. Symptoms can be effectively alleviated through the discontinuation of relevant medications, administration of hormones or immunosuppressants, plasma exchange, and lifestyle adjustments.
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Affiliation(s)
- Ling-Ling Xu
- Medical College, School of Medicine, Wuhan University of Science and Technology, Wuhan 430065, Hubei Province, China
| | - Jia-Xin Chen
- Medical College, School of Medicine, Wuhan University of Science and Technology, Wuhan 430065, Hubei Province, China
| | - Jing-Ping Cheng
- Department of Gerontology, CR & WISCO General Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430080, Hubei Province, China
| | - Ni Luo
- Department of Gerontology, CR & WISCO General Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430080, Hubei Province, China
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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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9
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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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Low CK, Wong HC, Apparow S, Yong SL. Insulin Autoimmune Syndrome - An After-Meal Roller Coaster Ride. J ASEAN Fed Endocr Soc 2024; 39:125-128. [PMID: 38863913 PMCID: PMC11163323 DOI: 10.15605/jafes.039.01.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/05/2023] [Indexed: 06/13/2024] Open
Abstract
Hypoglycemic disorders are rare in persons without diabetes, and clinical evaluation to identify its etiology can be challenging. We present a case of insulin autoimmune syndrome induced by carbimazole in a middle-aged Chinese man with underlying Graves' disease, which was managed conservatively with a combination of dietary modification and alpha-glucosidase inhibitor.
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Affiliation(s)
- Chee Koon Low
- Endocrine Unit, Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
| | - Hui Chin Wong
- Endocrine Unit, Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
| | - Saraswathy Apparow
- Endocrine Unit, Biochemical Genomic Research Centre, Institute for Medical Research, Kuala Lumpur, Malaysia
| | - Sy Liang Yong
- Endocrine Unit, Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
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11
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Kuruvilla P, John A, Murali A. Insulin autoimmunity associated with vitiligo: a rare case presentation. Endocrinol Diabetes Metab Case Rep 2024; 2024:22-0369. [PMID: 38428138 PMCID: PMC10959029 DOI: 10.1530/edm-22-0369] [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: 10/17/2022] [Accepted: 02/07/2024] [Indexed: 03/03/2024] Open
Abstract
Summary Insulin autoantibody syndrome (IAS) or Hirata's disease is a rare condition characterized by recurrent fasting hypoglycaemic and postprandial hyperglycaemic episodes. Insulin autoantibodies are diagnostic for the condition. Hirata's disease has been seen to be associated with other autoimmune conditions. Vitiligo is a common depigmentation disorder whose exact cause is unknown but thought to have an autoimmune aetiology. Although autoimmunity plays a role in the pathogenesis of both the diseases, association between the two has not been reported till date. In our case, a 72-year-old Indian woman with vitiligo for the past 30 years presented with recurrent episodes of fasting hypoglycaemia. She was found to have very high levels of fasting insulin, C-peptide, and insulin antibody and was diagnosed with IAS. Thus, we conclude that the clinical spectrum of Hirata's disease has to be taken as more heterogenous than previously assumed. Learning points Insulin autoantibody syndrome (IAS) or Hirata's disease is a rare condition characterized by recurrent fasting hypoglycaemic and postprandial hyperglycaemic episodes in which insulin plays a major role. Insulin autoantibodies are diagnostic for IAS. The endocrine insulin and its autoantibodies play a major role in the pathogenesis of the disease. Vitiligo is a common depigmentation disorder whose exact cause is unknown but thought to have an autoimmune aetiology. IAS and vitiligo are two diseases with autoimmune aetiology which has been seen to be associated with each other (the first case to be reported). The clinical spectrum of Hirata's disease has to be taken as more heterogenous than previously assumed. On dealing with autoimmune diseases, we should also keep in mind about other diseases with autoimmune pathogenesis.
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Affiliation(s)
| | - Angel John
- Department of Internal Medicine, Caritas Hospital, Kerala, India
| | - Ashith Murali
- Department of Internal Medicine, Caritas Hospital, Kerala, India
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12
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Gan L, Zhu X, Gao Y, Zhong M, Liao S, Huang G, Yan Y. A review on nondiabetic hypoglycemia from various causes: Case series report. Medicine (Baltimore) 2023; 102:e36273. [PMID: 38013348 PMCID: PMC10681503 DOI: 10.1097/md.0000000000036273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023] Open
Abstract
RATIONALE Hypoglycemia is common in patients with glucose regulation disorders and related diabetic treatments but is rare in nondiabetic patients. Severe hypoglycemia can cause harm to patients' cognition, consciousness, central nervous system, cardiovascular and cerebrovascular system, and even death. However, the most fundamental way to control hypoglycemia is to identify the cause and deal with the primary disease. This article introduces 3 cases of nondiabetic hypoglycemia with different causes, aiming to improve our understanding of nondiabetic hypoglycemia and improve the ability of early diagnosis and differential diagnosis. PATIENT CONCERNS Case 1 is a 19-year-old female with a history of recurrent coma, and magnetic resonance imaging and endoscopic ultrasound of the pancreas suggest insulinoma. Case 2 is a 74-year-old male with a history of viral hepatitis, and computerized tomography shows multiple nodules in the liver, which is diagnosed as liver cancer. Case 3 is a 39-year-old female with a history of taking methimazole, who tested positive for insulin antibodies, and was diagnosed with insulin autoimmune syndrome. DIAGNOSIS All 3 patients were diagnosed with nondiabetic hypoglycemia, but the causes varied, and included insulinoma, non-islet cell tumor-induced hypoglycemia, and insulin autoimmune syndrome. INTERVENTIONS Case 1 underwent pancreatic tail resection; case 2 refused anti-tumor treatment and received glucose injections for palliative treatment only; and case 3 stopped taking methimazole. OUTCOMES After surgery, the blood sugar in case 1 returned to normal, and the blood sugar in case 2 was maintained at about 6.0 mmol/L. The symptoms of hypoglycemia gradually improved in case 3 after stopping the medication. LESSONS Non-diabetic hypoglycemia requires further examination to clarify the cause, and the correct differential diagnosis can provide timely and effective treatment, improving the patient's prognosis.
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Affiliation(s)
- Lulu Gan
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Xuan Zhu
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Yue Gao
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Mingyao Zhong
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Shibo Liao
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Gao Huang
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Yimin Yan
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College of Wuhan University of Science and Technology, Wuhan, China
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13
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Horinishi Y, Ohta R, Sano C. A Case of Insulin Autoimmune Syndrome Accompanied With Systemic Joint Pain: A Case Report. Cureus 2023; 15:e47140. [PMID: 38021632 PMCID: PMC10650969 DOI: 10.7759/cureus.47140] [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: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Insulin autoimmune syndrome (IAS) is a rare disorder characterised by autoantibodies against endogenous insulin that cause spontaneous hypoglycemic episodes. Here, we present the case of a 66-year-old male with polyarticular pain and dizziness that was initially suspected to be an insulinoma. However, further testing confirmed the presence of IAS. The patient's joint pain fluctuated but improved with the control of blood glucose levels. Although the direct relationship between IAS and joint pain is not well established, individuals with a single autoimmune disorder may develop concurrent autoimmune conditions. Joint pain is prevalent in patients with autoimmune diseases. Although hypoglycemia may cause muscle cramps due to stress responses, direct musculoskeletal damage is uncommon. This case underscores the importance of differential diagnosis, particularly in differentiating between pancreatic cancer and the benign proliferation of pancreatic B cells. Elevated levels of insulin autoantibodies confirm IAS, whereas pancreatic cancer may manifest various symptoms and elevated cancer antigens (CA) 19-9. General physicians should comprehensively investigate hypoglycemia cases, particularly those associated with pancreatic enlargement, and continually monitor for potential malignancies.
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Affiliation(s)
| | | | - Chiaki Sano
- Community Medicine Management, Shimane University Faculty of Medicine, Izumo, JPN
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14
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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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15
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Corona-Meraz FI, Quintero-Castillo BP, Hernández-Palma LA, Machado-Sulbaran AC. Long COVID-19 and Insulin Autoimmune Syndrome: A Case Report. Clin Ther 2023; 45:e187-e192. [PMID: 37524570 DOI: 10.1016/j.clinthera.2023.06.026] [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: 03/10/2023] [Revised: 06/25/2023] [Accepted: 06/30/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE To describe a case report of a patient with symptoms associated with metabolic alterations 1 month after having COVID-19. METHODS Laboratory tests, clinical evaluations, and body composition assessments were performed by specialists. FINDINGS The patient presented excessive sweating, hot flashes, dizziness, blurred vision, and seizure. Laboratory tests indicated low glucose levels after convulsions (50, 42.7, and 55 mg/dL), high insulin levels (basal, 638 µIU/mL; 2-hour, >1000 µU/mL), and positivity for anti-insulin antibodies. The patient was diagnosed with insulin autoimmune syndrome. Treatment with azathioprine and nutritional recommendations improved remission. IMPLICATIONS SARS-CoV-2 infection or vaccination might induce insulin tolerance failure.
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Affiliation(s)
- Fernanda Isadora Corona-Meraz
- Departamento de Ciencias Biomédicas, Centro Universitario de Tonalá, Universidad de Guadalajara, Guadalajara, México
| | | | - Luis Alexis Hernández-Palma
- Instituto de Investigaciones en Comportamiento Alimentario y Nutrición, Centro Universitario del Sur, Universidad de Guadalajara, Guadalajara, México
| | - Andrea Carolina Machado-Sulbaran
- Instituto de Investigación en Cáncer en la Infancia y Adolescencia, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México.
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16
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Zhao L, He J, Ye S, Chen C, Zhu J, Xiao C, Wu T, Liu Z. Long-term follow-up after discharge witnesses a slow decline of insulin autoantibodies in patients with insulin autoimmune syndrome complicated with Grave's disease: a report of two cases. BMC Endocr Disord 2023; 23:177. [PMID: 37587407 PMCID: PMC10433660 DOI: 10.1186/s12902-023-01410-6] [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] [Received: 11/21/2022] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia characterized by high levels of blood insulin autoantibodies. It has been documented that drugs containing sulfhydryl groups may result in IAS. In this study, we present two cases of IAS induced by methimazole, along with their corresponding treatments and a long-term follow-up after hospitalization. CASE PRESENTATION We report two patients with Grave's disease (GD), carrying the HLA-DRB1 04:06 genotype, who experienced hypoglycemic episodes after taking methimazole. Inpatient treatments helped return their blood glucose levels to normal. Although no recurrences of hypoglycemia were present in the two cases studied, insulin autoantibodies remained positive for the previous follow-up sessions, which turned negative only three years after discharge. CONCLUSIONS GD patients who carry the HLA-DRB1 04:06 genotype are prone to IAS if they take drugs containing sulfhydryl groups. It may take time for the elimination of insulin autoantibodies after the recovery from the hypoglycemic episode in IAS patients.
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Affiliation(s)
- Lili Zhao
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Jinzhi He
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Shandong Ye
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China.
| | - Chao Chen
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Jie Zhu
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Chunchun Xiao
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Tingni Wu
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Zhicheng Liu
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, 230032, China.
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17
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Sehgal T, Ohri U, Mittal N, Attri P, Dishant F. A Case of Insulin Autoimmune Syndrome in an Indian Male Taking Alpha-Lipoic Acid. Cureus 2023; 15:e43743. [PMID: 37727171 PMCID: PMC10506126 DOI: 10.7759/cureus.43743] [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: 08/19/2023] [Indexed: 09/21/2023] Open
Abstract
Insulin autoimmune syndrome [IAS, Hirata disease (HD)] is a rare cause of recurrent spontaneous hypoglycemic episodes, characterized by high serum insulin levels and high titers of autoantibodies against endogenous insulin. We report a case of a previously healthy Indian male presenting with recurrent episodes of hypoglycemia with no prior exposure to exogenous insulin. Regular glucose monitoring was done. Laboratory tests showed insulin >1000 μIU/mL and C-peptide levels of 12.8 ng/ml. The patient had high titers of insulin autoantibodies (IAA) (>100 units/mL; normal range: <10 units/mL), which indicated a diagnosis of IAS. The patient was consuming alpha-lipoic acid; sulfhydryl-containing compounds have been linked to IAS. This case report highlights the importance of IAA titers in first-line investigations for hypoglycemia in a non-diabetic patient with strikingly high blood insulin levels and discusses the potential relationship between IAS and alpha-lipoic acid.
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Affiliation(s)
- Tanisha Sehgal
- Medicine and Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Uday Ohri
- Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Naveen Mittal
- Endocrinology and Diabetes, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Parmarth Attri
- Medicine and Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Fnu Dishant
- Medicine and Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
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18
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Galván R, Fernández-Riejos P, Sánchez Martínez PM, Rodríguez-Chacón C, Sánchez Mora C, León-Justel A. Complete laboratory diagnosis of Insulin Autoimmune Syndrome. Pract Lab Med 2023; 36:e00320. [PMID: 37649545 PMCID: PMC10462649 DOI: 10.1016/j.plabm.2023.e00320] [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: 02/10/2022] [Revised: 01/18/2023] [Accepted: 06/19/2023] [Indexed: 09/01/2023] Open
Abstract
The definition of Insulin autoimmune syndrome includes the presence of high levels of blood insulin and insulin autoantibodies. We encountered a 45-years-old white man with a high insulin serum value that do not fit with the C-peptide result. To discard or to confirm an analytical interference and diagnose a possible Insulin Autoimmune Syndrome we performed the following investigations: dilution linearity test, heterophilic antibody blocking, polyethylene glycol precipitation, measurements with alternative assays, and gel filtration chromatography by size exclusion. The latter technique confirmed that most of the insulin was complexed with a 150-kDa protein, corresponding to immunoglobulin G, identified as insulin autoantibodies. These antibodies were responsible for hypoglycemia attacks in the patient, who had a previous autoimmune disease. This case highlights the importance of carefully analyzing the results and ruling out possible interferences, as well as considering all kinds of pathologies, even if they are infrequent.
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Affiliation(s)
- Raquel Galván
- Laboratory Medicine Department, Virgen Macarena University Hospital, Av. Dr. Fedriani, 3, 41009, Seville, Andalusia, Spain
| | - Patricia Fernández-Riejos
- Laboratory Medicine Department, Virgen Macarena University Hospital, Av. Dr. Fedriani, 3, 41009, Seville, Andalusia, Spain
| | - Pilar María Sánchez Martínez
- Laboratory Medicine Department, Virgen Macarena University Hospital, Av. Dr. Fedriani, 3, 41009, Seville, Andalusia, Spain
| | - Carmen Rodríguez-Chacón
- Laboratory Medicine Department, Virgen Macarena University Hospital, Av. Dr. Fedriani, 3, 41009, Seville, Andalusia, Spain
| | - Catalina Sánchez Mora
- Laboratory Medicine Department, Virgen Macarena University Hospital, Av. Dr. Fedriani, 3, 41009, Seville, Andalusia, Spain
| | - Antonio León-Justel
- Laboratory Medicine Department, Virgen Macarena University Hospital, Av. Dr. Fedriani, 3, 41009, Seville, Andalusia, Spain
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19
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Teruya-Gibu AA, Ortiz-Guerra P, Arzapalo-Poma AA. Endocrine diseases associated with COVID-19 vaccination: case report. Rev Peru Med Exp Salud Publica 2023; 40:364-368. [PMID: 37991041 PMCID: PMC10953636 DOI: 10.17843/rpmesp.2023.403.12572] [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: 01/23/2023] [Accepted: 08/02/2023] [Indexed: 11/23/2023] Open
Abstract
SARS-CoV-2 vaccination is not free of adverse effects. We present two cases of endocrine involvement associated with COVID-19 vaccination. A 46-year-old woman who, after receiving the first COVID-19 vaccination dose, presented persistent fever and signs of thyrotoxicosis after being diagnosed with subacute thyroiditis associated with COVID-19 vaccination; the condition remitted with the use of corticoids. A 71-year-old male, who after COVID-19 vaccination, presented hyperinsulinemic hypoglycemia, testing positive for anti-insulin antibodies; he was diagnosed with autoimmune hypoglycemia associated with COVID-19 vaccination and received treatment with prednisone, controlling the episodes of hypoglycemia. In conclusion, endocrine diseases associated with COVID-19 vaccination are extremely rare and their timely detection allows adequate treatment.
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Affiliation(s)
- Alberto A Teruya-Gibu
- Servicio de Endocrinología, Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú
| | - Percy Ortiz-Guerra
- Servicio de Banco de Órganos y Laboratorio de Histocompatibilidad, Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú
| | - Abad A Arzapalo-Poma
- Servicio de Banco de Órganos y Laboratorio de Histocompatibilidad, Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú
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20
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Han CY, Ye XM, Lu JP, Jin HY, Xu WW, Wang P, Zhang M. Exogenous Insulin Antibody Syndrome in Patients with Type 2 Diabetes. Diabetes Metab Syndr Obes 2023; 16:1895-1902. [PMID: 37398942 PMCID: PMC10312206 DOI: 10.2147/dmso.s410349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/03/2023] [Indexed: 07/04/2023] Open
Abstract
Background Exogenous insulin antibody syndrome (EIAS) is an immunological disorder caused by circulating insulin antibodies (IAs), featuring hypersensitivity to exogenous insulin and insulin resistance. With the wide use of recombinant human insulin and insulin analogs, there has been a significant proliferation of EIAS. Case Report We describe two cases of diabetes mellitus (DM) with hyperinsulinemia and high serum levels of IAs. They had never been exposed to methimazole, glutathione, lipoic acid, and other sulfhydryl drugs, but they all received insulin treatment. The patient in case 1 had recurrent hypoglycemia before hospitalization. A prolonged oral glucose tolerance test (OGTT) showed hypoglycemia with inappropriately high insulin levels. The patient in case 2 was hospitalized for diabetic ketosis. An OGTT indicated hyperglycemia with hyperinsulinemia and low levels of C-peptide. IAs induced by exogenous insulin in the two patients with DM were positive at high titers, prompting a diagnosis of another condition-EIAS. Conclusion We discussed the differences between these two cases of EIAS in clinical manifestations and treatment and summarized all patients of EIAS treated in our department to date.
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Affiliation(s)
- Chen-Yu Han
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
| | - Xiao-Mei Ye
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
| | - Jia-Ping Lu
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
| | - Hai-Ying Jin
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
| | - Wei-Wei Xu
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
| | - Ping Wang
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
| | - Min Zhang
- Department of Endocrinology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People’s Republic of China
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21
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. An Uncommon Cause of Recurrent Presyncope, Dizziness, and Tachycardia: A Case Report of Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS). Biomedicines 2023; 11:1741. [PMID: 37371836 DOI: 10.3390/biomedicines11061741] [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: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Neurovegetative and autonomic symptoms are common presentations of various diseases, ranging from psychosomatic to severe organic disorders. A 23-year-old man presented with a history of recurrent presyncope, dizziness, and tachycardia. Repeated diagnostic work-up in various clinical settings could not identify any definite cause for approximately eight years. However, the incidental detection of postprandial and exercise-induced hypoglycemia was suggestive of an insulin-related disorder. A 72 h plasma glucose fasting test revealed endogenous hyperinsulinism. Upon imaging studies, no tumor mass potentially indicating insulinoma could be detected. 68Ga-DOTA-Exendin-4 PET/CT showed diffuse tracer enrichment throughout the whole pancreas. A subtotal pancreatectomy was performed, and the diagnosis of diffuse, adult-onset nesidioblastosis was established histopathologically. This corresponds to the clinical findings of a functional β-cell disorder, also known as non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). After nine months, the symptoms recurred, making complete pancreatectomy necessary. Postoperative laboratory evaluation exhibited no residual endogenous C-peptide production. This case illustrates the diagnostic challenges in patients presenting with unspecific, neurovegetative and autonomic symptoms with a severe and rare underlying cause.
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Affiliation(s)
- Martin Philipp Dieterle
- Center for Dental Medicine, Division of Oral Biotechnology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Center for Dental Medicine, Department of Orthodontics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8036 Graz, Austria
| | - Thorsten Steinberg
- Center for Dental Medicine, Division of Oral Biotechnology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Center for Dental Medicine, Division of Oral Biotechnology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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22
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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Dhaliwal KK, Bector G, Arora S, Singh A, Kalra S. An Uncommon Case of Recurrent Hypoglycemic Episodes in a Healthy Non-diabetic Male: Insulin Autoimmune Syndrome. Cureus 2023; 15:e41183. [PMID: 37525774 PMCID: PMC10387218 DOI: 10.7759/cureus.41183] [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: 06/30/2023] [Indexed: 08/02/2023] Open
Abstract
Insulin autoimmune syndrome is a rare cause of recurrent hypoglycemic episodes that can mimic various other pathological problems leading to unnecessary diagnostic assessments and interventions. Here, we report a case of a healthy non-diabetic male in his 50s presenting with recurrent episodes of hypoglycemia with no prior exposure to exogenous insulin. During a 72-hour fasting test, his glucose levels reached 22 mg/dl within less than three hours. The lab tests showed insulin of 1000 μIU/mL and C-peptide of 4.99 ng/ml. On further evaluation, high titers of insulin autoantibodies (IAA) >100 U/ml (normal = <10 U/ml) were consistent with insulin autoimmune syndrome diagnosis. This case thus highlights the importance of including IAA titers in first-line investigations for hypoglycemia in a non-diabetic patient with strikingly high blood insulin levels.
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Affiliation(s)
| | - Gaurav Bector
- Medicine and Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Saurabh Arora
- Endocrinology, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Amanpreet Singh
- Medicine and Surgery, Dayanand Medical College and Hospital, Ludhiana, IND
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Zhou L, Luo Y, Wang Y, Cheng Y, Zhang R, Zhang S, Gong S, Han X, Ji L. The clinical implications of fasting serum insulin levels in patients with insulin-treated type 2 diabetes: a cross-sectional survey. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2023; 4:1172208. [PMID: 37324170 PMCID: PMC10266272 DOI: 10.3389/fcdhc.2023.1172208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
Objective This study aimed to investigate the clinical implications of fasting serum insulin (FINS) levels in subjects with type 2 diabetes who were receiving insulin therapy. Methods A total of 1,553 subjects with type 2 diabetes [774 subjects who had never received insulin treatment (N-INS) and 779 subjects who were receiving insulin therapy (constant insulin treatment, C-INS)] admitted to the Department of Endocrinology and Metabolism of Peking University People's Hospital were enrolled in this study. Their FINS levels were measured and those with hyperinsulinemia were identified. The underlying mechanisms of hyperinsulinemia were revealed by measuring insulin antibodies (IAs) and analyzing changes in FINS levels before and after polyethylene glycol (PEG) precipitation. In addition, the clinical characteristics of patients with different types of hyperinsulinemia were compared. Results Higher FINS levels and a higher incidence (43.8%, 341/779) of hyperinsulinemia (FINS > 15μIU/mL) were observed in subjects with C-INS than in subjects with N-INS. Among subjects with C-INS and hyperinsulinemia, 66.9% (228/341) were IAs positive, and the incidence of IAs was found to be positively associated with FINS level. By performing PEG precipitation, we found that all subjects without IAs (i.e., those with real hyperinsulinemia) and 31.1% of subjects (71/228) with IAs (i.e., those with both real and IAs-related hyperinsulinemia) still had hyperinsulinemia after PEG precipitation, whereas FINS levels in the other 68.9% of subjects (157/228) with IAs were normal (IAs-related hyperinsulinemia) after PEG precipitation. Comparisons between the groups showed that subjects with real hyperinsulinemia showed more obvious insulin resistance characteristics, including higher lipid levels, BMIs, and homoeostasis model assessment2-estimated insulin resistance (HOMA2-IR) index, and were more likely to have hypertension, obesity, and metabolic syndromes (p < 0.05). However, the risk of hypoglycemia and glucose variability increased significantly in subjects with IAs compared with those without IAs. A cutoff of FINS to serum C-peptide ratio (≥ 9.3μIU/ng) could be used to screen IAs in clinical practice with 83.3% sensitivity and 70% specificity. Conclusions It is necessary to measure FINS in subjects with C-INS to distinguish between types of hyperinsulinemia, which should help to tailor treatment regimens.
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Affiliation(s)
- Lingli Zhou
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Yingying Luo
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Yan Wang
- Department of Endocrinology and Metabolism, People’s Hospital of Deyang City, Deyang, Sichuan, China
| | - Yao Cheng
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Rui Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Simin Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Siqian Gong
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Xueyao Han
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
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Ghantarchyan H, Fischer N, Karp D, Hamidi A. Methamphetamine-Induced Hypoglycemia: A Case Report and Literature Review. Cureus 2023; 15:e39158. [PMID: 37332469 PMCID: PMC10275691 DOI: 10.7759/cureus.39158] [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: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
We present a rare case of a 34-year-old male patient with a history of schizophrenia who was found to be persistently hypoglycemic after a positive toxicology screen for methamphetamine. The patient has had multiple admissions to the hospital for persistent hypoglycemia and was then transferred to our in-patient behavioral health unit (BHU). At this time, his toxicology screen was negative for methamphetamines. During his stay in the BHU, he was compliant with his psychiatric medications and was euglycemic despite having a poor appetite until he was discharged home. This patient was shortly readmitted to the hospital and found to be severely hypoglycemic and methamphetamine positive. Here, we present this rare case of methamphetamine-induced hypoglycemia. We emphasize our work-up, treatment, and our suggested theory of why methamphetamines are the likely cause of hypoglycemia.
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Affiliation(s)
| | - Nina Fischer
- Internal Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - David Karp
- Internal Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Afshin Hamidi
- Endocrinology and Diabetes, Arrowhead Regional Medical Center, Colton, USA
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Marzinotto I, Pittman DL, Williams AJK, Long AE, Achenbach P, Schlosser M, Akolkar B, Winter WE, Lampasona V. Islet Autoantibody Standardization Program: interlaboratory comparison of insulin autoantibody assay performance in 2018 and 2020 workshops. Diabetologia 2023; 66:897-912. [PMID: 36759347 PMCID: PMC10036445 DOI: 10.1007/s00125-023-05877-9] [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: 08/30/2022] [Accepted: 12/21/2022] [Indexed: 02/11/2023]
Abstract
AIMS/HYPOTHESIS The Islet Autoantibody Standardization Program (IASP) aims to improve the performance of immunoassays measuring autoantibodies in type 1 diabetes and the concordance of results across laboratories. IASP organises international workshops distributing anonymised serum samples to participating laboratories and centralises the collection and analysis of results. In this report, we describe the results of assays measuring IAA submitted to the IASP 2018 and 2020 workshops. METHODS The IASP distributed uniquely coded sera from individuals with new-onset type 1 diabetes, multiple islet autoantibody-positive individuals, and diabetes-free blood donors in both 2018 and 2020. Serial dilutions of the anti-insulin mouse monoclonal antibody HUI-018 were also included. Sensitivity, specificity, area under the receiver operating characteristic curve (ROC-AUC), partial ROC-AUC at 95% specificity (pAUC95) and concordance of qualitative/quantitative results were compared across assays. RESULTS Results from 45 IAA assays of seven different formats and from 37 IAA assays of six different formats were submitted to the IASP in 2018 and 2020, respectively. The median ROC-AUC was 0.736 (IQR 0.617-0.803) and 0.790 (IQR 0.730-0.836), while the median pAUC95 was 0.016 (IQR 0.004-0.021) and 0.023 (IQR 0.014-0.026) in the 2018 and 2020 workshops, respectively. Assays largely differed in AUC (IASP 2018 range 0.232-0.874; IASP 2020 range 0.379-0.924) and pAUC95 (IASP 2018 and IASP 2020 range 0-0.032). CONCLUSIONS/INTERPRETATION Assay formats submitted to this study showed heterogeneous performance. Despite the high variability across laboratories, the in-house radiobinding assay (RBA) remains the gold standard for IAA measurement. However, novel non-radioactive IAA immunoassays showed a good performance and, if further improved, might be considered valid alternatives to RBAs.
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Affiliation(s)
- Ilaria Marzinotto
- San Raffaele Diabetes Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - David L Pittman
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Alistair J K Williams
- Diabetes and Metabolism, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Anna E Long
- Diabetes and Metabolism, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Peter Achenbach
- Institute of Diabetes Research, Helmholtz Munich, German Research Center for Environmental Health, Neuherberg, Germany.
| | - Michael Schlosser
- Department of General Surgery, Visceral, Thoracic and Vascular Surgery, University Medical Center Greifswald, Greifswald, Germany
- Institute of Pathophysiology, Research Group of Predictive Diagnostics, University Medical Center Greifswald, Karlsburg, Germany
| | - Beena Akolkar
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - William E Winter
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Vito Lampasona
- San Raffaele Diabetes Research Institute, San Raffaele Scientific Institute, Milan, Italy.
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Liu Y, Ping F, Yu J, Lv L, Zhao Y, Qi M, Li W, Xu L, Yu M, Li M, Zhang H, Li Y. Hypoglycemia Caused by Exogenous Insulin Antibody Syndrome: A Large Single-Center Case Series From China. J Clin Endocrinol Metab 2023; 108:713-717. [PMID: 36219196 DOI: 10.1210/clinem/dgac578] [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] [Received: 05/07/2022] [Revised: 09/10/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Exogenous insulin antibody syndrome (EIAS) can lead to unexpected and potentially life-threatening recurrent hypoglycemia. OBJECTIVE We aimed to better define autoimmune hypoglycemia caused by EIAS in patients with diabetes and shed light on the improvements in the identification and intervention for this rare but possibly life-threatening condition. METHODS We summarized the clinical characteristics of autoimmune hypoglycemia caused by EIAS in 23 patients with diabetes. Furthermore, we performed human leukocyte antigen (HLA) genotyping of 10 patients. RESULTS We identified a high frequency of autoimmune comorbidities (21.7%), food or drug allergy (48%), insulin allergy (30%), lipodystrophy at the insulin injection sites (22%), and antinuclear antibodies (25%) in the patients. Alternation between hyperglycemia and hypoglycemia was observed in more than 90% of the patients. Most patients showed a high insulin autoantibody titer (>90%) and inappropriately increased insulin concentration (insulin/C-peptide molar ratio >7, >85%). We detected similar frequencies of DRB1*0405-DQB1*0401 and DRB1*0901-DQB1*0303 compared with previously reported frequencies in type 1 diabetes, and a lower frequency of DRB1*0406 compared with insulin autoimmune syndrome. The spontaneous remission rate exceeded 70%. CONCLUSION Predisposing factors for autoimmune hypoglycemia caused by EIAS include a strong autoimmune background. Susceptible HLA genotypes for type 1 diabetes or insulin autoimmune syndrome might not explain susceptibility to this condition. Additionally, insulin autoantibodies and the insulin/C-peptide molar ratio are reliable screening options. The prognosis for this condition is favorable. Monitoring of insulin and insulin autoantibodies may contribute to treatment effectiveness.
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Affiliation(s)
- Yiwen Liu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Fan Ping
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jie Yu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lu Lv
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yuan Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Mengya Qi
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lingling Xu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Miao Yu
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ming Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Huabing Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yuxiu Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Monteiro SS, Santos TS, Dores J. Novel management of insulin autoimmune syndrome with methylprednisolone and flash glucose monitoring. ANNALES D'ENDOCRINOLOGIE 2023; 84:83-85. [PMID: 36252848 DOI: 10.1016/j.ando.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Sílvia Santos Monteiro
- Division of Endocrinology, Diabetes and Metabolism. Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar 4099-001 Porto, Portugal.
| | - Tiago Silva Santos
- Division of Endocrinology, Diabetes and Metabolism. Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar 4099-001 Porto, Portugal
| | - Jorge Dores
- Division of Endocrinology, Diabetes and Metabolism. Centro Hospitalar Universitário do Porto, Largo Professor Abel Salazar 4099-001 Porto, Portugal
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Effect of Adding Intravenous Somatostatin to Rectal Indomethacin on Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-risk Patients: A Double-blind Randomized Placebo-controlled Clinical Trial. J Clin Gastroenterol 2023; 57:204-210. [PMID: 34049378 DOI: 10.1097/mcg.0000000000001563] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/05/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has an important role in the treatment of pancreaticobiliary disorders. GOALS Considering the high prevalence and importance of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) and the controversial findings, we aimed to determine the effect of adding intravenous somatostatin to rectal indomethacin on the incidence of PEP in high-risk patients. STUDY In this prospective study, 530 patients underwent ERCP during March 2018 and February 2019. Patients were randomized into 2 groups. The intervention group received a bolus injection of 250 μg somatostatin followed by an infusion of 500 μg of somatostatin for 2 hours. In both groups, 100 mg of pre-ERCP suppository indomethacin was administrated. All patients were screened for PEP symptoms and signs for 24 hours after ERCP (Iranian Registry of Clinical Trials code: IRCT20080921001264N11). RESULTS A total of 376 patients were finally analyzed. PEP was the most common adverse event with 50 (13.2%) episodes, including 21 (5.5%) mild, 23 (6.1%) moderate, and 6 (1.2%) severe. The rate of PEP was 15.2% in the control group and 11.4% in the intervention group ( P =0.666). The incidence of post-ERCP hyperamylasemia was 21.7% in the control group and 18.2% in the intervention group ( P =0.395). No death occurred. CONCLUSIONS In this study administration of somatostatin plus indomethacin could safely reduce the rate of post-ERCP hyperamylasemia and PEP in the intervention group compared with the control group, but the differences were not significant. Further studies with larger sample sizes are required.
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Lin M, Chen Y, Ning J. Insulin Autoimmune Syndrome: A Systematic Review. Int J Endocrinol 2023; 2023:1225676. [PMID: 36844104 PMCID: PMC9946739 DOI: 10.1155/2023/1225676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/17/2023] Open
Abstract
Insulin autoimmune syndrome (IAS) is a rare endocrine disorder characterized by recurrent episodes of severe hypoglycemia, markedly elevated serum insulin, and positive insulin autoantibodies. In recent years, various countries have reported it one after another. It can be seen that we must pay attention to this disease. The diagnosis of IAS is challenging, requiring a careful workup aimed at excluding other causes of hyperinsulinemic hypoglycemia. High levels of insulin autoantibodies are found in patients, and C-peptide is not parallel to insulin, which could be diagnostic. IAS is a self-limiting disease with a good prognosis. Its treatment mainly includes symptomatic supportive treatment, such as adjusting the diet and using acarbose and other drugs to delay the absorption of glucose to prevent hypoglycemia. For patients with severe symptoms, available treatments may include drugs that reduce pancreatic insulin secretion (such as somatostatin and diazoxide), immunosuppressants (glucocorticoids, zaprin, and rituximab), and even plasma exchange to remove autoantibodies from the body. This review provides a comprehensive analysis of the epidemiology, pathogenesis, clinical manifestations, diagnosis and identification, and monitoring and treatment management of IAS.
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Affiliation(s)
- MingXu Lin
- Department of Endocrinology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen 518110, Guangdong, China
| | - YuHua Chen
- Guangdong Medical University, Zhanjiang 524000, Guangdong, China
- Department of Endocrinology, Longgang District People's Hospital of Shenzhen, Shenzhen 518172, Guangdong, China
| | - Jie Ning
- Department of Endocrinology, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen 518110, Guangdong, China
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He Y, Xu A, Yu D, Lv S, Xu H. Hypoglycemic Coma Caused by Methimazole-Induced Insulin Autoimmune Syndrome, a Case Study. Diabetes Metab Syndr Obes 2023; 16:1149-1154. [PMID: 37122676 PMCID: PMC10145436 DOI: 10.2147/dmso.s406290] [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: 01/29/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023] Open
Abstract
Islet autoimmune syndrome (IAS) is an autoimmune disease caused by high concentrations of insulin autoantibodies (IAA) in the blood. It is characterized by hyperinsulinemia and spontaneous hypoglycemia. The incidence of IAS is low, and the hypoglycemia symptom is usually mild. Hence, the severe manifestations (up to seizures and coma) are rarely reported. Here, we reported two cases of Graves' disease who developed insulin autoimmune syndrome after methimazole treatment. The patients exhibited sudden hypoglycemic coma after receiving methimazole treatment for approximately 2 or 6 months. The patients' serum glucose levels were below 2.8 mmol/L, and laboratory tests showed high levels of serum insulin and high titers of insulin autoantibodies. Patient 1 discontinued methimazole treatment and the hypoglycemic symptoms disappeared after 7 days. However, patient 2 experienced severe hypoglycemia after discontinuation of methimazole, and the patient condition improved after glucocorticoid therapy. He developed thyroid storm during the treatment, and his condition improved after receiving standard treatment procedures for thyroid storm. To the best of our knowledge, this is the first case report of IAS in Graves' disease with thyroid storm.
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Affiliation(s)
- Yinhui He
- Department of Endocrinology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang Province, 323000, People’s Republic of China
- Correspondence: Yinhui He; Haiyan Xu, Email ;
| | - Aihua Xu
- Department of Endocrinology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang Province, 323000, People’s Republic of China
| | - Danqing Yu
- Department of Endocrinology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang Province, 323000, People’s Republic of China
| | - Suzhen Lv
- Department of Endocrinology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang Province, 323000, People’s Republic of China
| | - Haiyan Xu
- Department of Endocrinology, Lishui Municipal Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang Province, 323000, People’s Republic of China
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Wood AJ, Kasireddy V, Chitturi S, Walsh JP. Insulinoma Presenting With Postprandial Hypoglycemia in a Pregnant Woman With MEN-1. JCEM CASE REPORTS 2023; 1:luac015. [PMID: 37908256 PMCID: PMC10578399 DOI: 10.1210/jcemcr/luac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Indexed: 11/02/2023]
Abstract
Insulinomas are rare insulin-secreting tumors of pancreatic origin that cause hypoglycemia and can be associated with multiple endocrine neoplasia type 1 (MEN1). While rare, they are the most common cause of hypoglycemia related to endogenous hyperinsulinism. A 28-year-old woman with known MEN1 presented with postprandial hypoglycemia in the second trimester of pregnancy. Prior to her presentation she was known to have several pancreatic neuroendocrine tumors that had been stable on serial imaging, but no history of hypoglycemia. She was managed with dietary intervention during pregnancy and gave birth to a healthy baby at 37 weeks' gestation. After pregnancy, hypoglycemia initially resolved, but then recurred at 8 months post partum. Magnetic resonance imaging showed several pancreatic neoplasms with the largest lesion measuring 29 mm in the pancreatic tail, unchanged from previous imaging. After localization with a selective arterial calcium stimulation test, the patient underwent successful distal pancreatectomy with resolution of symptoms. This case is unusual in that her initial presentation was during pregnancy, she had predominantly postprandial rather than fasting hypoglycemia, and her symptoms remitted for several months after delivery. Key learning points are to have a low index of suspicion for an insulinoma when there is a history of MEN1 and the need for a pragmatic approach to diagnosis and treatment during pregnancy.
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Affiliation(s)
- Anna J Wood
- Department of Endocrinology, Royal Darwin Hospital, Casuarina, Northern Territory 0810, Australia
- Menzies School of Health Research , Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Vidya Kasireddy
- Department of Endocrinology, Royal Darwin Hospital, Casuarina, Northern Territory 0810, Australia
| | - Sridhar Chitturi
- Department of Endocrinology, Royal Darwin Hospital, Casuarina, Northern Territory 0810, Australia
- School of Medicine, Flinders University, Northern Territory Medical Program, Tiwi, Northern Territory, Australia
| | - John P Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Australia
- Medical School, University of Western Australia, Crawley, Australia
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Foreman RE, Meek CL, Roberts GP, George AL, Reimann F, Gribble FM, Kay RG. LC-MS/MS based detection of circulating proinsulin derived peptides in patients with altered pancreatic beta cell function. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1211:123482. [PMID: 36242807 PMCID: PMC7614196 DOI: 10.1016/j.jchromb.2022.123482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 02/02/2023]
Abstract
Routine immunoassays for insulin and C-peptide have the potential to cross-react with partially processed proinsulin products, although in healthy patients these are present at such low levels that the interference is insignificant. Elevated concentrations of proinsulin and des-31,32 proinsulin arising from pathological conditions, or injected insulin analogues, however can cause significant assay interferences, complicating interpretation. Clinical diagnosis and management therefore sometimes require methods that can distinguish true insulin and C-peptide from partially processed proinsulin or injected insulin analogues. In this scenario, the high specificity of mass spectrometric analysis offers potential benefit for patient care. A high throughput targeted LC-MS/MS method was developed as a fit for purpose investigation of insulin, insulin analogues, C-peptide and proinsulin processing intermediates in plasma samples from different patient groups. Using calibration standards and bovine insulin as an internal standard, absolute concentrations of insulin and C-peptide were quantified across a nominal human plasma postprandial range and correlated strongly with immunoassay-based measurements. The ability to distinguish between insulin, insulin analogues and proinsulin intermediates in a single extraction is an improvement over existing immunological based techniques, offering the advantage of exact identification of the species being measured. The method promises to aid in the detection of circulating peptides which have previously been overlooked but may interfere with standard insulin and C-peptide immunoassays.
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Affiliation(s)
- Rachel E Foreman
- Wellcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom; Peptidomics and Proteomics Core Facility, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Claire L Meek
- Wellcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom; Department of Clinical Biochemistry/Wolfson Diabetes & Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Geoffrey P Roberts
- Wellcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Amy L George
- Peptidomics and Proteomics Core Facility, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Frank Reimann
- Wellcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Fiona M Gribble
- Wellcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.
| | - Richard G Kay
- Wellcome-MRC Institute of Metabolic Science-Metabolic Research Laboratories, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom; Peptidomics and Proteomics Core Facility, Level 4, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.
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Senthilkumaran S, Miller SW, Williams HF, Thirumalaikolundusubramanian P, Vaiyapuri S, Patel K. Hirata's disease (insulin autoimmune syndrome) following envenomation by a common krait. Toxicon 2022; 219:106923. [PMID: 36116739 DOI: 10.1016/j.toxicon.2022.09.009] [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: 07/21/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 11/30/2022]
Abstract
Snakebite envenomation is known to cause local as well as systemic haematological, myotoxic and neurological effects. Adverse effects on the endocrine system following envenomation are rarely reported. Hirata's disease, also known as insulin autoimmune syndrome (IAS) is a rare disorder that causes hypoglycaemia due to excessive production of insulin autoantibodies. This report describes a rare case of IAS which developed in a snakebite victim following envenomation by a common krait and antivenom treatment. The patient was initially treated with dextrose and corticosteroids, although plasmapheresis was required to reduce the concentration of insulin antibodies and normalise the patient's glucose level. The patient then made an uneventful recovery without permanent sequelae. This report demonstrates the impacts of envenomation by a common krait on developing Hirata's disease and creates awareness among clinicians who treat snakebite envenomation.
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Affiliation(s)
| | - Stephen W Miller
- The Poison Control Center, Children's Hospital of Philadelphia, USA
| | | | | | | | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading, UK.
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Zeng Y, Li G, Song H. Polyethylene Glycol Precipitation to Avoid Misdiagnosis of Insulin Autoimmune Syndrome: A Case Report and Testing Pathway in Medical Laboratories. Ann Lab Med 2022; 42:609-611. [PMID: 35470281 PMCID: PMC9057819 DOI: 10.3343/alm.2022.42.5.609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/20/2022] [Accepted: 03/30/2022] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yuping Zeng
- Department of Laboratories Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Guixing Li
- Department of Laboratories Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Haolan Song
- Department of Laboratories Medicine, West China Hospital, Sichuan University, Chengdu, China
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Affiliation(s)
- Amy W Baughman
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Nancy J Wei
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Peter F Hahn
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Brenna W Casey
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - M Lisa Zhang
- From the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (A.W.B., N.J.W., B.W.C.), Radiology (P.F.H.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
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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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Haverkamp GLG, Ijzerman RG, Kooter J, Krul-Poel YHM. The After-Dinner Dip. N Engl J Med 2022; 386:2130-2136. [PMID: 35648706 DOI: 10.1056/nejmcps2106883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Gertrud L G Haverkamp
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
| | - Richard G Ijzerman
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
| | - Jos Kooter
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
| | - Yvonne H M Krul-Poel
- From the Department of Internal Medicine and Endocrinology, Amsterdam University Medical Center, Amsterdam
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Takahashi K, Anno T, Takenouchi H, Iwamoto H, Horiya M, Kimura Y, Kawasaki F, Kaku K, Tomoda K, Kaneto H. Serious diabetic ketoacidosis induced by insulin allergy and anti-insulin antibody in a subject with type 2 diabetes mellitus. J Diabetes Investig 2022; 13:1788-1792. [PMID: 35587395 PMCID: PMC9533051 DOI: 10.1111/jdi.13838] [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: 03/21/2022] [Revised: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes mellitus, and is characterized by hyperglycemia, metabolic acidosis and increased total ketone body concentrations. The main mechanism of DKA is a lack of insulin in the body. It has been reported that some immunological response is associated with insulin therapy. Herein, we report a case of serious DKA, which was induced by insulin allergy and anti‐insulin antibody. This case clearly shows that DKA can be induced by insulin allergy and anti‐insulin antibodies in individuals with type 2 diabetes treated with insulin. Furthermore, we should know that as the required insulin dose might be very high under severe insulin resistance and serious DKA in such cases, we should increase the insulin dose appropriately while monitoring pH, base excess and other factors.
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Affiliation(s)
- Kaio Takahashi
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Haruka Takenouchi
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Hideyuki Iwamoto
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Megumi Horiya
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, 701-0192, Japan
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Oest L, Roden M, Müssig K. Comparison of patient characteristics between East Asian and non-East Asian patients with insulin autoimmune syndrome. Clin Endocrinol (Oxf) 2022; 96:328-338. [PMID: 34778997 DOI: 10.1111/cen.14634] [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] [Received: 06/25/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Insulin autoimmune syndrome (IAS) is the third most common cause of spontaneous hypoglycaemia in Japan but very rare in the rest of the world. We aimed to identify factors, which are associated with the occurrence of IAS and which may differ between East Asian and non-East Asian patients. DESIGN A PubMed search using the search terms 'insulin autoimmune syndrome' and 'Hirata disease' revealed a total of 287 reports of IAS cases, including one previously unpublished own case. RESULTS Mean age (±standard deviation) was 52 ± 19 years in East Asian and 54 ± 21 years in non-East Asian patients (p > .05). In both groups, there were more females. Mean body mass index was lower in East Asian than in non-East Asian patients (23.0 ± 4.3 vs. 27.1 ± 5.6 kg/m2 , p < .0001). Postprandial hypoglycaemia was more common in non-East Asian patients (p < .05). East Asian patients took more frequently antithyroid medications and non-East Asian patients angiotensin-converting enzyme (ACE) inhibitors (both p < .0001). Graves' disease and other autoimmune diseases were more frequently observed in East Asian patients (both p < .01). Parameters of glucose metabolism were comparable in both groups, independent of diabetes diagnosis (p > .05), except for insulin that was higher in East Asian compared to non-East Asian metabolically healthy patients (p < .01). Human leukocyte antigen (HLA)-DRB1*0406 was the most frequent HLA-type in East Asian patients (p < .0001), whereas DRB1*0403 and *0404 were more frequent in non-East Asian patients (both p < .05). Non-East Asian patients received more secondary treatments, including plasmapheresis and rituximab, whereas medication discontinuation was more common in East Asian patients (all p < .05). Outcome was similar in both groups (p > .05). CONCLUSIONS Factors associated with IAS markedly differ between East Asian and non-East Asian patients, with autoimmune disorders, particularly Graves' disease, antithyroid medications, and HLA-DRB1*0406 more prevalent in East Asian patients and cardiovascular and plasma cell diseases, ACE inhibitors and HLA-DRB1*0403 more prevalent in non-East Asian patients.
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Affiliation(s)
- Lisa Oest
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
| | - Karsten Müssig
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
- Department of Internal Medicine and Gastroenterology, Niels Stensen Hospitals, Franziskus Hospital Harderberg, Georgsmarienhütte, Germany
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Pérez-García A, Torrecilla-Parra M, Fernández-de Frutos M, Martín-Martín Y, Pardo-Marqués V, Ramírez CM. Posttranscriptional Regulation of Insulin Resistance: Implications for Metabolic Diseases. Biomolecules 2022; 12:biom12020208. [PMID: 35204710 PMCID: PMC8961590 DOI: 10.3390/biom12020208] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/14/2022] Open
Abstract
Insulin resistance defines an impairment in the biologic response to insulin action in target tissues, primarily the liver, muscle, adipose tissue, and brain. Insulin resistance affects physiology in many ways, causing hyperglycemia, hypertension, dyslipidemia, visceral adiposity, hyperinsulinemia, elevated inflammatory markers, and endothelial dysfunction, and its persistence leads to the development metabolic disease, including diabetes, obesity, cardiovascular disease, or nonalcoholic fatty liver disease (NAFLD), as well as neurological disorders such as Alzheimer’s disease. In addition to classical transcriptional factors, posttranscriptional control of gene expression exerted by microRNAs and RNA-binding proteins constitutes a new level of regulation with important implications in metabolic homeostasis. In this review, we describe miRNAs and RBPs that control key genes involved in the insulin signaling pathway and related regulatory networks, and their impact on human metabolic diseases at the molecular level, as well as their potential use for diagnosis and future therapeutics.
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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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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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[Insulin autoimmune syndrome : A rare, but important differential diagnosis of hypoglycemia]. Internist (Berl) 2021; 63:217-220. [PMID: 34698875 PMCID: PMC8813699 DOI: 10.1007/s00108-021-01180-0] [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] [Accepted: 09/15/2021] [Indexed: 11/22/2022]
Abstract
Eine 69-jährige Patientin mit rezidivierenden schweren Hypoglykämien wurde zur weiteren Diagnostik der Medizinischen Hochschule Hannover zugewiesen. Zuvor hatte die Patientin nach einem Stenting, das aufgrund einer peripheren arteriellen Verschlusskrankheit (pAVK) erforderlich war, mit einer Clopidogreleinnahme begonnen. Das Vorliegen eines Insulinoms und eines paraneoplastischen Syndroms wurde ausgeschlossen. Trotz niedrig normaler Blutzuckerkonzentrationen fanden sich erhöhte Insulin- und Insulinautoantikörperkonzentrationen. Diagnostiziert wurde ein Insulinautoimmunsyndrom, a.e. (am ehesten) ausgelöst durch vorausgegangene Clopidogreleinnahme. Eine Behandlung mithilfe der Immunadsorption wurde initiiert; diese erzielte eine signifikante Reduktion der hypoglykämischen Ereignisse und ein anhaltendes Therapieansprechen über 3 Monate.
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Esposito C, Ugo Garzarella E, Santarcangelo C, Di Minno A, Dacrema M, Sacchi R, Piccinocchi G, Piccinocchi R, Daglia M. Safety and efficacy of alpha-lipoic acid oral supplementation in the reduction of pain with unknown etiology: A monocentric, randomized, double-blind, placebo-controlled clinical trial. Biomed Pharmacother 2021; 144:112308. [PMID: 34649217 DOI: 10.1016/j.biopha.2021.112308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Extensive evidence suggests that alpha-lipoic acid (ALA) is effective in diabetic neuropathy pain management. However, little is known on its safety and efficacy in reducing idiopathic pain in normoglycemic subjects. The aim of this study was to evaluate ALA food supplement safety and efficacy in the reduction of different forms of idiopathic pain. METHODS Two-hundred and ten normoglycemic adults suffering from idiopathic pain (i.e. 57 subjects with primitive neuropathic pain, 141 subjects with arthralgia with unknown etiology, and 12 subjects with idiopathic myalgia) were randomized to receive placebo, 400 mg/day, or 800 mg/day of ALA. Participants underwent two visits (at baseline = t0, and after 2 months = t1) in which two validated questionaries for pain (numerical rating scale [NRS] and visual analogue scale [VAS]) were collected; fasting blood glucose assessment, adverse effects, and renal and hepatic toxicity were also monitored. RESULTS At t1, none of subjects treated with ALA reported a decreased glycemia or adverse effects. The treated subjects showed a significant reduction in NRS (p < 0.001) while the placebo group did not show any NRS reduction (p = 0.86). Similar results were also obtained for VAS. Statistical analysis aimed at detecting possible differences in NRS and VAS scores among treatment groups based on the source of pain did not reveal any significant effect. CONCLUSIONS Since the management of idiopathic pain is challenging for physicians, the use of ALA food supplements could be a feasible option, based on its safety and efficacy compared to commonly-used analgesic drugs.
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Affiliation(s)
- Cristina Esposito
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Emanuele Ugo Garzarella
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Cristina Santarcangelo
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Alessandro Di Minno
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy; CEINGE-Biotecnologie Avanzate, Via Gaetano Salvatore 486, 80145 Naples, Italy
| | - Marco Dacrema
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Roberto Sacchi
- Applied Statistic Unit, Department of Earth and Environmental Sciences, University of Pavia, viale Taramelli 24, 27100 Pavia, Italy
| | - Gaetano Piccinocchi
- Comegen S.c.S., Società Cooperativa Sociale di Medici di Medicina Generale, Viale Maria Bakunin, 41, 80125 Naples, Italy
| | - Roberto Piccinocchi
- Level 1 Medical Director Anaesthesia and Resuscitation A. U. O. Luigi Vanvitelli, Via Santa Maria di Costantinopoli, 80138 Naples, Italy
| | - Maria Daglia
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy; International Research Center for Food Nutrition and Safety, Jiangsu University, 212013 Zhenjiang, China.
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Pineda-Cortel MRB, Bunag JAA, Mamerto TP, Abulencia MFB. Differential gene expression and network-based analyses of the placental transcriptome reveal distinct potential biomarkers for gestationaldiabetes mellitus. Diabetes Res Clin Pract 2021; 180:109046. [PMID: 34530062 DOI: 10.1016/j.diabres.2021.109046] [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: 08/04/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022]
Abstract
AIMS Gestational diabetes mellitus (GDM) is a common complication during pregnancy affecting the mother and fetus. With the problems encountered with the oral glucose tolerance test (OGTT), we aim to identify potential early biomarkers of GDM. METHODS A cross-sectional study was conducted among 80 pregnant women. Blood samples were collected every trimester, and total RNA was isolated. After quality control and library preparation, next-generation sequencing was performed. Differential expression analysis was done. Enriched Gene Ontology: Biological Processes (GO: BP) terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were identified. Gene co-expression networks were constructed. Protein-protein Interaction (PPI) networks were then built from modules significantly correlated with Hemoglobin A1c. Genes with the highest degree of interaction were identified as hub genes. RESULTS IGKV2D-28 and PTPRG were consistently differentially expressed among the three comparisons. Top enriched GO: BP terms and KEGG pathways are linked to immune responses. Orange (r = 0.59, p = 0.02) and purple modules (r = 0.41, p = 0.02) of the GDM cohorts in the first and second trimesters, respectively, significantly correlated with Hemoglobin A1c. HDAC8 of the orange module and MPO and CRISP3 of the purple module were identified as hub genes. CONCLUSIONS In this study, potential biomarkers of GDM were identified, namely, IGKV2D-28, PTPRG, HDAC8, MPO, and CRISP3.
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Affiliation(s)
- Maria Ruth B Pineda-Cortel
- Department of Medical Technology, Faculty of Pharmacy, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines; The Graduate School, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines; Research Center for the Natural and Applied Sciences, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines.
| | - Jose Angelo A Bunag
- Research Center for the Natural and Applied Sciences, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines
| | - Therriz P Mamerto
- Research Center for the Natural and Applied Sciences, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines; Department of Biochemistry, Faculty of Pharmacy, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines
| | - Miguel Francisco B Abulencia
- Research Center for the Natural and Applied Sciences, University of Santo Tomas, España Boulevard, 1015 Manila, Philippines
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Gullo D, Magliozzo M, Strano A, Piazza VG, Stabile G, Belfiore A. Insulin autoimmune syndrome misdiagnosed as an insulinoma in a woman presenting with a pancreatic cystic lesion and taking alpha lipoic acid: a lesson to be learned. Hormones (Athens) 2021; 20:593-595. [PMID: 33175361 DOI: 10.1007/s42000-020-00261-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/06/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Damiano Gullo
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy.
- Endocrine Unit, Garibaldi-Nesima Hospital, Via Palermo 636, I-95131, Catania, Italy.
| | - Miriam Magliozzo
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | - Adriana Strano
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
| | | | | | - Antonino Belfiore
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi-Nesima Hospital, Catania, Italy
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Batra CM, Kumar K, Goyal M. Steroid-Refractory Insulin Autoimmune Syndrome Treated With Rituximab and Continuous Glucose Monitoring. Cureus 2021; 13:e16513. [PMID: 34430127 PMCID: PMC8375604 DOI: 10.7759/cureus.16513] [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] [Accepted: 07/20/2021] [Indexed: 11/16/2022] Open
Abstract
A 67-year-old female presented with severe hypoglycemia with a blood glucose of 34 mg/dl five hours after having dinner. She did not have diabetes and had no access to oral hypoglycemic agents, insulin, or any other drug known to cause hypoglycemia. She was a known case of primary hypothyroidism euthyroid on treatment. The physical examination was unremarkable. Her liver, renal functions, thyroid, and adrenal functions were normal. At a blood sugar level of 23 mg/dl, her serum insulin was 24,000 uU/ml (normal: <3 uU/ml) and C-peptide was 16.2 ng/ml (normal: 0-0.6 ng/ml), which were were very high. As the serum insulin levels were very high, insulin autoimmune syndrome (IAS) was suspected. Insulin autoantibodies (IAAs) were positive [87.2 units/ml (normal: <12)]. Imaging with contrast-enhanced CT (CECT) of the abdomen, endoscopic ultrasonography, and 68 gallium octreotide DOTANOC whole-body PET-CT scan did not reveal any pancreatic or extra-pancreatic tumor. Eventually, the patient was diagnosed with IAS. She was started on high-dose prednisolone, diazoxide, and octreotide in addition to low carbohydrate meals. Hypoglycemic episodes continued for one month despite this therapy. Remission was achieved only after two doses of rituximab 1 g IV infusion were given. Serum insulin levels decreased to 230 uU units from 24,000 uU/ml, and the patient's hypoglycemic and hyperglycemic episodes were normalized. We used continuous glucose monitoring with the FreeStyle Libre glucose monitoring system, and the management of the patient was greatly facilitated by this.
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Affiliation(s)
- Chandar M Batra
- Endocrinology, Indraprastha Apollo Hospitals, New Delhi, New Delhi, IND
| | - Kiran Kumar
- Endocrinology, Indraprastha Apollo Hospitals, New Delhi, New Delhi, IND
| | - Monika Goyal
- Endocrinology, Indraprastha Apollo Hospitals, New Delhi, New Delhi, IND
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Dharmaputra RK, Wan KL, Samad N, Herath M, Wong J, Sarlos S, Holdsworth SR, Naderpoor N. A novel approach to a rare case of non-islet cell hypoglycaemia. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210040. [PMID: 34236039 PMCID: PMC8284944 DOI: 10.1530/edm-21-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/14/2021] [Indexed: 12/24/2022] Open
Abstract
SUMMARY Insulin autoimmune syndrome (IAS) is a rare cause of non-islet cell hypoglycaemia. Treatment of this condition is complex and typically involves long-term use of glucocorticoids. Immunotherapy may provide an alternative in the management of this autoimmune condition through the suppression of antibodies production by B-lymphocyte depletion. We present a case of a 62-year-old male, with refractory hypoglycaemia initially presenting with hypoglycaemic seizure during an admission for acute psychosis. Biochemical testing revealed hypoglycaemia with an inappropriately elevated insulin and C-peptide level and no evidence of exogenous use of insulin or sulphonylurea. Polyethylene glycol precipitation demonstrated persistently elevated free insulin levels. This was accompanied by markedly elevated anti-insulin antibody (IA) titres. Imaging included CT with contrast, MRI, pancreatic endoscopic ultrasound and Ga 68-DOTATATE position emission tomography (DOTATATE PET) scan did not reveal islet cell aetiology for hyperinsulinaemia. Maintenance of euglycaemia was dependent on oral steroids and dextrose infusion. Complete resolution of hypoglycaemia and dependence on glucose and steroids was only achieved following treatment with plasma exchange and rituximab. LEARNING POINTS Insulin autoimmune syndrome (IAS) should be considered in patients with recurrent hyperinsulinaemic hypoglycaemia in whom exogenous insulin administration and islet cell pathologies have been excluded. Biochemical techniques play an essential role in establishing high insulin concentration, insulin antibody titres, and eliminating biochemical interference. High insulin antibody concentration can lead to inappropriately elevated serum insulin levels leading to hypoglycaemia. Plasma exchange and B-lymphocyte depletion with rituximab and immunosuppression with high dose glucocorticoids are effective in reducing serum insulin levels and hypoglycaemia in insulin autoimmune syndrome (IAS). Based on our observation, the reduction in serum insulin level may be a better indicator of treatment efficacy compared to anti-insulin antibody (IA) titre as it demonstrated greater correlation to the frequency of hypoglycaemia and to hypoglycaemia resolution.
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Affiliation(s)
- R K Dharmaputra
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
| | - K L Wan
- Monash Health Pathology, Monash Health, Victoria, Australia
| | - N Samad
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
| | - M Herath
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - J Wong
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Department of Endocrinology, Monash Health, Victoria, Australia
| | - S Sarlos
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Department of Endocrinology, Monash Health, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Victoria, Australia
| | - S R Holdsworth
- Department of Immunology, Monash Health, Victoria, Australia
| | - N Naderpoor
- Diabetes and Vascular Medicine Department, Monash Health, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
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