1
|
Brown N, Elston MS. Systematic Review-Type B Insulin Resistance With Isolated Hypoglycemia and Suppressed Insulin. J Clin Endocrinol Metab 2024; 109:936-943. [PMID: 37552775 DOI: 10.1210/clinem/dgad467] [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: 04/04/2023] [Revised: 06/26/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE Type B insulin resistance syndrome is a rare autoimmune disorder affecting glucose homeostasis, characterized by serum autoantibodies to the insulin receptor (AIRAbs). Patients typically present with severe insulin resistance. A mixed hyper- and hypoglycemia phenotype may also occur, as may isolated hypoglycemia. The classic biochemical pattern comprises elevated insulin levels despite hypoglycemia; however, a small proportion of cases demonstrate "isolated hypoglycemia with low insulin." The primary objectives of this systematic review were to identify the clinical characteristics and outcome of this subgroup. DESIGN Systematic review of cases with hypoglycemia with suppressed insulin. Exclusions: hyperglycemia, elevated insulin, AIRAbs not confirmed. METHODS PubMed, Medline, and Embase databases were searched up until February 2023 and complemented by manual citation search. The Joanna Briggs Institute critical appraisal checklist for case reports was used to assess bias. RESULTS A total of 5342 articles were identified after duplicate removal. Eleven, all case reports, met all inclusion criteria and were included. Cases belonging to this subgroup were more diverse in sex, age, and ethnicity when compared with type B insulin resistance as a whole. Of the 11 cases, 3 developed lymphoma. High-dose corticosteroid therapy appeared to be effective therapy for the hypoglycemia, with often rapid response. CONCLUSIONS Isolated hypoglycemia with low insulin forms a rare subgroup of type B insulin resistance. These patients lack the common characteristics of hyperinsulinemic hypoglycemia and hyperglycemia/insulin resistance. Furthermore, while coexisting autoimmune disease is commonly observed, there is potentially an association with aggressive lymphoma, the onset of which may be delayed.
Collapse
Affiliation(s)
- Natasha Brown
- Endocrinology Unit, Te Whatu Ora Waikato, Hamilton 3204, New Zealand
| | - Marianne S Elston
- Endocrinology Unit, Te Whatu Ora Waikato, Hamilton 3204, New Zealand
- Waikato Clinical Campus, University of Auckland, Hamilton 3204, New Zealand
| |
Collapse
|
2
|
Brown N, Du Toit S, Conaglen J, Elston M. A typical presentation of type B insulin resistance syndrome with isolated hypoglycaemia and suppressed insulin. BMJ Case Rep 2022; 15:e246523. [PMID: 35185019 PMCID: PMC8860015 DOI: 10.1136/bcr-2021-246523] [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] [Accepted: 12/30/2021] [Indexed: 11/04/2022] Open
Abstract
Type B insulin resistance syndrome is a rare autoimmune disorder affecting glucose homeostasis characterised by the presence of serum autoantibodies to the insulin receptor. Typically, these patients present with severe insulin resistance although a mixed hyperglycaemic and hypoglycaemic phenotype may also occur, as can an exceptionally rare isolated hypoglycaemia presentation. The classic biochemical pattern comprises elevated insulin levels despite significant hypoglycaemia. We report an adult man presenting with isolated hypoglycaemia and suppressed serum insulin and C-peptide levels. He demonstrated evidence of autoimmunity with positive antinuclear antibodies, reactive lymphadenopathy and cytopaenias but did not meet the criteria for systemic lupus erythematosus and underlying malignancy was not identified despite extensive investigation. Insulin receptor antibodies were present. Treatment with prednisone led to resolution of hypoglycaemia, with no recurrence after 36 months of follow-up. However, 42 months after initial presentation, he represented with high-grade lymphoma.
Collapse
Affiliation(s)
- Natasha Brown
- Department of Endocrinology, Waikato District Health Board, Hamilton, New Zealand
| | - Stephen Du Toit
- Department of Biochemistry, Waikato District Health Board, Hamilton, New Zealand
| | - John Conaglen
- Department of Endocrinology, Waikato District Health Board, Hamilton, New Zealand
| | - Marianne Elston
- Univ Auckland, Hamilton, New Zealand
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
| |
Collapse
|
3
|
Geng L, Wong CL, Liao B, Lin Y, Han H, Lam KSL, Xu A, Lee CH, Tam VHK. Development of a novel diagnostic assay for insulin receptor autoantibodies based on a patient with autoimmune hypoglycaemia. Front Endocrinol (Lausanne) 2022; 13:1029297. [PMID: 36387920 PMCID: PMC9642853 DOI: 10.3389/fendo.2022.1029297] [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: 08/27/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
Differential diagnosis of hypoglycaemia can at times be challenging for patients who appear to be well. Here we identify the case of a 66-year-old Chinese man presenting with recurrent episodes of fasting hypoglycaemia and confusion without any other manifestations. He had no personal or family history of diabetes, nor was he on any hypoglycaemic drugs. The fasting insulin levels were elevated while the C-peptide and pro-insulin levels were slightly low or normal. Antibodies against insulin were negative and levels of insulin-like growth factors were normal. A series of imaging diagnosis excluded the presence of insulinoma or ectopic insulin-secreting neuroendocrine tumor. Ultimately, insulin receptor autoantibodies (IRAb) were detected by both immunoprecipitation assay and enzyme-linked immunosorbent assay (ELISA) developed in house. In a cell study, the immunoglobulins isolated from this patient exerted insulin-like effects on stimulation of post-insulin receptor signaling and glucose uptake as well as inhibited 125I-insulin binding with insulin receptors. Collectively, this patient was diagnosed with IRAb-induced autoimmune hypoglycaemia. Although this patient had no obvious immune disorders, several autoantibodies were identified in his plasma samples, suggesting the patient might have mild aberrant autoimmunity and therefore generated IRAb. IRAb-related disease is uncommon and possibly underdiagnosed or missed due to the lack of simple detection methods for IRAb. Our in-house user-friendly ELISA kit provides a valuable tool for diagnosis of this disease.
Collapse
Affiliation(s)
- Leiluo Geng
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Cheuk-Lik Wong
- Diabetes Centre, Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong, Hong Kong SAR, China
| | - Boya Liao
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China
| | - Ying Lin
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hao Han
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Karen S. L. Lam
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Aimin Xu
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- *Correspondence: Aimin Xu, ; Chi-Ho Lee, ; Vicki H. K. Tam,
| | - Chi-Ho Lee
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- *Correspondence: Aimin Xu, ; Chi-Ho Lee, ; Vicki H. K. Tam,
| | - Vicki H. K. Tam
- Diabetes Centre, Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong, Hong Kong SAR, China
- *Correspondence: Aimin Xu, ; Chi-Ho Lee, ; Vicki H. K. Tam,
| |
Collapse
|
4
|
Rao G, Chauhan YV, Varthakavi PK, Bhagwat N. A Lean Lady With Acanthosis Nigricans and Uncontrolled Diabetes Mellitus. Cureus 2020; 12:e11330. [PMID: 33304668 PMCID: PMC7719472 DOI: 10.7759/cureus.11330] [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] [Indexed: 11/22/2022] Open
Abstract
A 47-year-old Asian Indian woman presented with uncontrolled hyperglycaemia and osmotic symptoms despite multiple oral antidiabetic medications and insulin. She had a history of recurrent oral ulcers, profound weight loss, and intermittent fever for one and a half years before the presentation. She had severe acanthosis nigricans, although her body mass index (BMI) was 14.6 kg/m2. Her blood glucose remained uncontrolled despite very large dosages of intravenous insulin (more than 12,000 units daily). Evaluation for possible underlying collagen vascular diseases and malignancies were negative. Her serum insulin levels were high. She tested negative for anti-insulin antibodies but positive for anti-insulin-receptor antibodies. She improved with a pulse dose of intravenous methylprednisolone but relapsed within one month. A second pulse dose was given following which a complete remission of diabetes and regression of acanthosis was observed. Type B insulin resistance, a rare cause of severe insulin resistance, may respond favourably to immunosuppressive therapy with high-dose methylprednisolone.
Collapse
Affiliation(s)
- Gururaja Rao
- Department of Endocrinology, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai, IND
| | - Yash V Chauhan
- Department of Endocrinology, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai, IND
| | - Premlata K Varthakavi
- Department of Endocrinology, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai, IND
| | - Nikhil Bhagwat
- Department of Endocrinology, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai, IND
| |
Collapse
|
5
|
Censi S, Mian C, Betterle C. Insulin autoimmune syndrome: from diagnosis to clinical management. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:335. [PMID: 30306074 DOI: 10.21037/atm.2018.07.32] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Autoimmune forms of hypoglycemia are a rare cause of low blood sugar levels among Caucasians, and often go misdiagnosed, exposing patients to lengthy series of pointless, potentially harmful and expensive tests. There are two types of autoimmune hypoglycemia. One is insulin autoimmune syndrome (IAS), which is characterized by hyperinsulinemic hypoglycemia, elevated insulin autoantibody (IAA) titers, no prior exposure to exogenous insulin, and no of pathological abnormalities of the pancreatic islets. This condition is also known as "Hirata's disease". The other is type B insulin resistance syndrome (TBIRS), a rare autoimmune disorder resulting in a broad array of abnormalities in glucose homeostasis-from hypoglycemia to extremely insulin-resistant hyperglycemia-caused by the presence of insulin receptor autoantibodies (IRAbs). This review focuses on these two syndromes, describing their epidemiology, possible genetic background, clinical presentation, pathophysiology, diagnosis and treatment.
Collapse
Affiliation(s)
- Simona Censi
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Caterina Mian
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Corrado Betterle
- Endocrinology Unit, Department of Medicine (DIMED), University of Padova, Padova, Italy
| |
Collapse
|
6
|
Ismail AAA. The insulin autoimmune syndrome (IAS) as a cause of hypoglycaemia: an update on the pathophysiology, biochemical investigations and diagnosis. Clin Chem Lab Med 2017; 54:1715-1724. [PMID: 27071154 DOI: 10.1515/cclm-2015-1255] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/23/2016] [Indexed: 12/11/2022]
Abstract
Insulin autoimmune syndrome (IAS) is considered to be very rare in Caucasians. Understanding its pathophysiology is paramount in (a) appreciating its potential impact on analyses of pancreatic hormones and (b) explaining its highly variable clinical manifestations in non-diabetic, non-acutely ill patients with indeterminate hypoglycaemia. The underlying aetiology of IAS is the presence of variable affinity/avidity endogenous insulin antibodies in significant amounts. The two types of insulin antibodies namely antibodies which bind insulin and/or proinsulin(s) and receptor antibodies (insulin mimetic) will be discussed. Their biochemical and immunological roles in causing hypoglycaemia will be highlighted. Clinical manifestations of IAS can vary from mild and transient to spontaneous, severe and protracted hypoglycaemia necessitating in extreme cases plasmapheresis for glycaemic control. Antibodies of IAS can interfere in pancreatic immunoassay tests causing erroneous and potentially misleading results. Thorough testing for endogenous insulin antibodies must be considered in the investigations of non-diabetic, non-acutely ill patients with indeterminate and/or unexplained hypoglycaemia.
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW To review the epidemiology, pathophysiology, clinical features, and management of type B insulin resistance syndrome. RECENT FINDINGS Type B insulin resistance syndrome is a rare disorder caused by autoantibodies to the insulin receptor. This disorder is most frequently reported in middle-aged black women and is invariably associated with other autoimmune diseases. Typically, refractory transient hyperglycemia and extreme insulin resistance are the cardinal features, but hypoglycemia may also occur. Traditionally, the high reported mortality rate was typically attributed to the hypoglycemia. There is no well standardized treatment regimen. However, recent therapeutic advances with combination immunomodulatory therapy have led to significant reported improvements in hypoglycemia-associated mortality and durability of remission. SUMMARY We review the literature on the pathophysiology and clinical features of type B insulin resistance syndrome and highlight the complexities and recent advances in the management of this disorder.
Collapse
Affiliation(s)
- Devina L Willard
- aSection of Endocrinology, Diabetes, and Nutrition, Boston Medical Center and Boston University School of Medicine bDepartment of Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | | |
Collapse
|
8
|
Lim HC, Munshi LB, Sharon D. Persistent Hypoglycemia in Patient with Hodgkin's Disease. Case Rep Oncol Med 2015; 2015:820286. [PMID: 26839722 PMCID: PMC4709603 DOI: 10.1155/2015/820286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 11/25/2015] [Accepted: 12/15/2015] [Indexed: 11/17/2022] Open
Abstract
Hypoglycemia is a rare complication of Hodgkin's disease. Several explanations have been postulated but the exact pathophysiology is not well understood. We are presenting a case of newly diagnosed Stage IV Hodgkin's disease that developed persistent and recurrent hypoglycemia despite giving glucagon, repeated 50% dextrose, and D5 and D10 continuous infusion. Hypoglycemia workup showed the C-peptide level to be low. Patient was suspected of having hypoglycemia related to lymphoma and was given a trial of prednisone which resolved the hypoglycemic episodes and made the patient euglycemic for the rest of his hospital stay. The presence of a substance that mimicked the effects of insulin was highly suspected. Several case reports strengthen the hypothesis of an insulin-like growth factor or antibodies secreted by the cancer cells causing hypoglycemia in Hodgkin's disease but none of them have been confirmed. Further investigation is warranted to more clearly define the pathophysiology of persistent hypoglycemia in patients with Hodgkin's disease.
Collapse
Affiliation(s)
- Harold Cinco Lim
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
| | - Lubna Bashir Munshi
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
| | - David Sharon
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
- Section of Hematology and Oncology, Monmouth Medical Center, Long Branch, NJ 07740, USA
| |
Collapse
|
9
|
Zhou S, Jiang L, Sun M. Recurrent hypoglycemic coma as the initial and single clinical manifestation of advanced hepatocellular carcinoma. J Gastrointest Cancer 2015; 46:64-7. [PMID: 25407746 DOI: 10.1007/s12029-014-9670-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Shutong Zhou
- The Fifth Affiliated Hospital of Peking University (Beijing Hospital), Beijing, China
| | | | | |
Collapse
|
10
|
Dynkevich Y, Rother KI, Whitford I, Qureshi S, Galiveeti S, Szulc AL, Danoff A, Breen TL, Kaviani N, Shanik MH, Leroith D, Vigneri R, Koch CA, Roth J. Tumors, IGF-2, and hypoglycemia: insights from the clinic, the laboratory, and the historical archive. Endocr Rev 2013; 34:798-826. [PMID: 23671155 DOI: 10.1210/er.2012-1033] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Tumors of mesenchymal and epithelial origin produce IGF-2, which activates pathways in the tumors. In a minority of patients, the tumors (hepatomas, fibromas, and fibrosarcomas are the most common among many) release into the circulation enough IGF-2-related peptides to mimic the fasting hypoglycemia characteristic of patients with insulin-producing islet-cell tumors. Rarely, markedly elevated IGF-2 levels produce somatic changes suggestive of acromegaly. Typically, the elevated IGF-2 levels are associated with suppressed plasma levels of insulin, IGF-1, and GH. Complicating the pathophysiology are the IGF binding proteins (IGFBPs) that can bind IGF-2 and IGF-1, modifying hormone metabolism and action. IGFBP concentrations are often altered in the presence of these tumors. At the cellular level, the 3 hormone-related ligands, IGF-2, IGF-1, and insulin, all bind to 4 (or more) types of IGF-1 receptor (IGF-1R) and insulin receptor (IR). Each receptor has its own characteristic affinity for each ligand, a tyrosine kinase, and overlapping profiles of action in the target cells. The IGF-2R, in addition to binding mannose-6-phosphate-containing proteins, provides an IGF-2 degradation pathway. Recent evidence suggests IGF-2R involvement also in signal transduction. Surgery, the treatment of choice, can produce a cure. For patients not cured by surgery, multiple therapies exist, for the tumor and for hypoglycemia. Potential future therapeutic approaches are sketched. From 1910 to 1930, hypoglycemia, insulin, insulinomas, and non-islet-cell tumors were recognized. The latter third of the century witnessed the emergence of the immunoassay for insulin; the IGFs, their binding proteins, and assays to measure them; and receptors for the insulin-related peptides as well as the intracellular pathways beyond the receptor. In closing, we replace non-islet-cell tumor hypoglycemia, an outdated and misleading label, with IGF-2-oma, self-explanatory and consistent with names of other hormone-secreting tumors.
Collapse
Affiliation(s)
- Yevgeniya Dynkevich
- MD, FACP, Investigator, Feinstein Institute for Medical Research, Laboratory of Diabetes and Diabetes-Related Research, 350 Community Drive, Manhasset, NY 11030.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
|
12
|
Abstract
BACKGROUND Hypoglycemia is a frequently encountered cause of altered mental status in clinical practice. OBJECTIVES To report a rare case with hypoglycemia-induced coma as the sole and initial clinical manifestation of a hepatic tumor. CASE REPORT A previously healthy 32-year-old man presenting with acute change in consciousness was found to have hepatoma related hypoglycemia. CONCLUSION This case highlights the importance of a hepatic evaluation in, otherwise, unexplained hypoglycemic coma in high prevalence areas of hepatocellular carcinoma such as the Asian-Pacific region.
Collapse
|
13
|
Daniel AL, Houlihan JL, Blum JS, Walsh JP. Type B insulin resistance developing during interferon-alpha therapy. Endocr Pract 2009; 15:153-7. [PMID: 19289328 DOI: 10.4158/ep.15.2.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To report a rare case of diabetes caused by type B insulin resistance due to development of insulin receptor autoantibodies during treatment of hepatitis C with interferon-alpha and ribavirin. METHODS Clinical and laboratory findings in the case are presented. The literature on type B insulin resistance and interferon-induced autoimmunity is reviewed. RESULTS A 55-year-old African American man with hepatitis C was treated with interferon and ribavirin. Eight months later, he presented with rapid onset of hyperglycemia, profound weakness, and weight loss. Severe hyperglycemia persisted despite insulin infusion rates as high as 125 U/h. The presence of insulin receptor autoantibodies was confirmed by immunoprecipitation of recombinant human insulin receptor with patient serum. Assays for autoantibodies to islet cell antigens and glutamic acid decarboxylase were negative. The interferon and ribavirin were discontinued. His insulin requirement spontaneously declined to low levels over a 6-month period. Two years after discharge of the patient, insulin receptor autoantibodies could no longer be demonstrated in his serum. He remains euglycemic and is no longer taking insulin. CONCLUSION This case demonstrates that type B insulin resistance can occur as a complication of interferon-alpha therapy. To our knowledge, this is the first reported case in the United States of type B insulin resistance with development of insulin receptor autoantibodies during treatment with interferon-alpha.
Collapse
Affiliation(s)
- Amanda L Daniel
- Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | | |
Collapse
|
14
|
Abstract
Autoimmune syndromes are a rare cause of hypoglycemia characterized by elevated levels of insulin in the presence of either anti-insulin antibodies (insulin autoimmune syndrome) or anti-insulin receptor antibodies (type B insulin resistance). Insulin autoimmune syndrome is the third leading cause of hypoglycemia in Japan, but has rarely been described in the non-Asian population.In the current study, we report the clinical and biochemical characteristics and clinical course of 2 white patients with insulin autoimmune syndrome, and present a literature review of non-Asian patients reported with insulin autoimmune syndrome. Also, we describe the clinical and biochemical characteristics of patients reported in the literature with type B insulin resistance who manifested hypoglycemia. We compare the clinical and laboratory features of insulin autoimmune syndrome and type B insulin resistance with each other and with other forms of hyperinsulinemic hypoglycemia.Autoimmune forms of hypoglycemia are uncommon. However, they should be considered in any patient with hypoglycemia in the setting of unsuppressed insulin levels associated with anti-insulin or anti-insulin receptor antibodies. Making the correct diagnosis may spare a hypoglycemic patient from an unnecessary pancreatic surgical procedure.
Collapse
Affiliation(s)
- Beatrice C Lupsa
- From Clinical Endocrinology Branch (BCL, AYC, EKC, PG), National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, United States; and University of Cambridge Metabolic Research Laboratories (MAS, RKS), Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | | | | | | | | |
Collapse
|
15
|
Coelho R, Wells J, Symth J, Semple R, O'Rahilly S, Eaton S, Hussain K. Severe hypoinsulinaemic hypoglycaemia in a premature infant associated with poor weight gain and reduced adipose tissue. HORMONE RESEARCH 2007; 68:91-8. [PMID: 17377394 DOI: 10.1159/000100974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Accepted: 01/17/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypoglycaemia is common in preterm and intrauterine growth retarded (IUGR) newborns. Although preterm and IUGR infants have limited adipose tissue stores, the role of adipose tissue and the associated adipocytokines in glucose physiology is not known. AIM We report the case of a premature intrauterine growth retarded infant who had poor weight gain for the first 6 weeks of life and then developed severe hypoinsulinaemic hypoketotic hypoglycaemia. RESULTS There was markedly reduced adiposity with low serum leptin and adiponectin levels. Total energy expenditure and body composition measurements showed that body fat as a percentage of weight averaged 7% at 20 weeks and 28% at 28 weeks. At 20 weeks of age, the patient was equivalent to a deficit of >2 SD scores of body fat, but average fatness by 28 weeks. The hypoglycaemia completely resolved when the patient started gaining weight with an increase in fat mass and a concomitant increase in serum leptin and adiponectin level. CONCLUSIONS Although the precise mechanism of this patient's severe hypoglycaemia is unclear, further studies are required to understand the role of adipose tissue and adipocytokines in glucose homeostasis in preterm and IUGR infants.
Collapse
Affiliation(s)
- Raquel Coelho
- Department of Endocrinology, Great Ormond Street Hospital for Children NHS Trust and the Institute of Child Health, University College London, London, UK
| | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
A 64-year-old nondiabetic woman presented with spells of lightheadedness and diaphoresis associated with lethargy and hunger of 2 weeks' duration. Physical examination was unremarkable; however, her fasting plasma glucose was 66 mg/dl, with concurrent plasma insulin of 171 microIU/ml (normal, 5-27 microIU/ml). Her C-peptide and pro-insulin levels were elevated, with negative insulin antibody and negative urinary sulfonylurea levels. Abdominal computed tomographic scan demonstrated a 5 x 4-cm mass in the tail of the pancreas and many liver metastases. She underwent resection of the pancreatic mass, radiofrequency ablation, and cauterization of hepatic lesions. Histology confirmed pancreatic insulinoma. Ten months later, she was free of hypoglycemic symptoms, with normal plasma insulin C-peptide and significantly decreased proinsulin levels. Insulinomas are rare, predominantly benign tumors. Surgery is the only curative treatment. Octreotide can be used to control hormone secretion and tumor growth. Other treatments include hepatic embolization, radiotherapy, chemotherapy, and liver transplantation.
Collapse
Affiliation(s)
- Tuan-Huy Tran
- Department of Internal Medicine, Section on Endocrinology and Related Diseases, Ochsner Clinic Foundation, New Orleans, LA 70121, USA
| | | | | |
Collapse
|
17
|
Soares-Welch CV, Zeldenrust SR, Conover CA, Grant CS, Service FJ. Hodgkin's lymphoma manifesting with hypoglycemia. Endocr Pract 2003; 9:96-7. [PMID: 12917097 DOI: 10.4158/ep.9.1.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Cacia V Soares-Welch
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, Rochester, Minnesota 55905, USA
| | | | | | | | | |
Collapse
|
18
|
Arioglu E, Andewelt A, Diabo C, Bell M, Taylor SI, Gorden P. Clinical course of the syndrome of autoantibodies to the insulin receptor (type B insulin resistance): a 28-year perspective. Medicine (Baltimore) 2002; 81:87-100. [PMID: 11889410 DOI: 10.1097/00005792-200203000-00001] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Elif Arioglu
- Diabetes Branch, National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, Maryland 20892-1829, USA
| | | | | | | | | | | |
Collapse
|
19
|
Nakamura T, Kishi A, Nishio Y, Maegawa H, Egawa K, Wong NC, Kojima H, Fujimiya M, Arai R, Kashiwagi A, Kikkawa R. Insulin production in a neuroectodermal tumor that expresses islet factor-1, but not pancreatic-duodenal homeobox 1. J Clin Endocrinol Metab 2001; 86:1795-800. [PMID: 11297620 DOI: 10.1210/jcem.86.4.7429] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
We studied a 60-yr-old female with a brain tumor who showed severe symptoms of hypoglycemia (plasma glucose, 2.2 mmol/L) and hyperinsulinemia (1.28 nmol/L) after radiotherapy. The cystic brain tumor contained proinsulin and insulin at concentrations of 13.6 and 1.22 nmol/L, respectively. Immunohistochemical studies showed the tumor cells were ectodermal in origin but not endodermal, based on three diagnostic features of neuroectodermal tumors 1) pseudorosette formation noted under light microscopy, 2) finding of a small number of dense core neurosecretory granules on electron microscopy, and 3) positive immunostaining for both neuronal specific enolase and protein gene product 9.5. These cells also expressed the transcription factor, neurogenin-3, NeuroD/beta 2, and islet factor I, which are believed to be transcription factors in neuroectoderm as well as in pancreatic islet cells, but not pancreatic-duodenal homeobox 1, Pax4, or Nkx2.2. In addition, they did not express glucagon, somatostatin, or glucagon-like peptide-1. Our results show the presence of proinsulin in an ectoderm cell brain tumor that does not express the homeobox gene, pancreatic-duodenal homeobox 1, but expresses other transcription factors, i.e. neurogenin3, NeuroD/beta 2, and islet factor-1, which are related to insulin gene expression in the brain tumor.
Collapse
Affiliation(s)
- T Nakamura
- Department of Anatomy, Shiga University of Medical Science, Otsu, Shiga 520-2129, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Uto H, Matsuoka H, Murata M, Okamoto T, Miyata Y, Hori T, Ido A, Hirono S, Hayashi K, Tsubouchi H. A case of chronic hepatitis C developing insulin-dependent diabetes mellitus associated with various autoantibodies during interferon therapy. Diabetes Res Clin Pract 2000; 49:101-6. [PMID: 10963820 DOI: 10.1016/s0168-8227(00)00143-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We report a case of chronic hepatitis C presenting insulin-dependent diabetes mellitus (IDDM) associated with various autoantibodies including possible anti-insulin receptor antibody (AIRA) during interferon (IFN) therapy. A 57-year-old man having chronic hepatitis C virus (HCV) infection with chronic thyroiditis received IFN therapy. The thyroid function was well-controlled by administration of thyroid hormone, although thyroid autoantibodies were positive. At 15 weeks after starting IFN (reaching 530 million units of total dose), marked thirst happened, with increased fasting plasma glucose level (488 mg/dl) and decreased daily urinary C peptide immunoreactivity level (less than 4.2 microg/day). IDDM occurred with anti-nuclear antibody (ANA), anti-DNA antibody and possible AIRA, and thyroid autoantibodies titers increased, but without pancreatic islet cell antibody and anti-glutamic acid decarboxylase antibody. Administration of IFN was stopped and insulin treatment was started, but plasma glucose level was not controlled well. AIRA became negative 2 months later, however, insulin antibody (IA) was positive when tested after 18 months. Serum HCV RNA has been negative, and a normal level of serum transaminase has been observed since IFN therapy. It is likely that IFN therapy induced the immunological disturbance and resulted in occurrence of various autoantibodies and IDDM in the patient.
Collapse
Affiliation(s)
- H Uto
- Department of Internal Medicine II, Miyazaki Medical College, Kiyotake 5200, 889-1601, Miyazaki, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Seckl MJ, Mulholland PJ, Bishop AE, Teale JD, Hales CN, Glaser M, Watkins S, Seckl JR. Hypoglycemia due to an insulin-secreting small-cell carcinoma of the cervix. N Engl J Med 1999; 341:733-6. [PMID: 10471459 DOI: 10.1056/nejm199909023411004] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- M J Seckl
- Department of Cancer Medicine, Imperial College School of Medicine, London.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Autoimmune hypoglycemia is a rare but fascinating syndrome of hypoglycemia caused by the interaction of endogenous antibodies with insulin or the insulin receptor. Awareness of autoimmune hypoglycemia is important because the syndrome may produce severe neuroglycopenic symptoms and may be confused with the presence of an insulinoma. A correct diagnosis is important to avoid unnecessary surgical intervention in patients who are best treated with conservative support, watchful waiting, or in some cases, immunosuppressive therapy.
Collapse
Affiliation(s)
- J B Redmon
- Department of Medicine, University of Minnesota Medical School, Minneapolis, USA.
| | | |
Collapse
|
23
|
Lloyd RV, Erickson LA, Nascimento AG, Klöppel G. Neoplasms Causing Nonhyperinsulinemic Hypoglycemia. Endocr Pathol 1999; 10:291-297. [PMID: 12114765 DOI: 10.1007/bf02739771] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Non-islet cell tumor hypoglycemia (NICTH) is uncommon. Many of the tumors associated with NICTH are mesenchymal tumors, although carcinomas are also involved in some cases. High serum levels of insulin-like growth factor II (IGF-II) have been associated with NICTH. Analysis of 4 pituitary tumors, 2 adrenocortical tumors, 42 solitary fibrous tumors, and 23 other mesenchymal tumors for IGF-II protein and mRNA showed that most mesenchymal tumors expressed IGF-II protein and mRNA, although only 4 of 48 patients had associated hypoglycemia. Tumor size was related to IGF-II production. Tumors less than 5 cm were usually negative for IGF-II mRNA, whereas 92.3% of tumors greater than 9 cm were positive for IGF-II mRNA. These results show that IGF-II mRNA and protein can be readily detected in many tumors, even when the tumors are not associated with clinical hypoglycemia. The expression and production of this growth factor cannot accurately predict patients with clinical evidence of hypoglycemia.
Collapse
|
24
|
Di Cerbo A, Tassi V, Scillitani A, Zoppetti G, De Filippis V. Characterization of insulin autoantibodies in a patient with autoimmune hypoglycemia. J Endocrinol Invest 1995; 18:299-304. [PMID: 7560813 DOI: 10.1007/bf03347817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A 60-year-old man referred because of hypoglycemic bouts was found to have insulin autoantibodies. Total plasma insulin was as high as 1.44 nmol/l. Both plasma free insulin and C-peptide were in the normal range. The indirect immunofluorescence technique showed positivity for antinuclear antibodies. The T-lymphocyte populations in the peripheral blood were normal. When serum binding capacity for pork insulin was measured, antibodies binding pork insulin were not detected. The patient's serum bound 125I-insulin. The binding protein was identified to be an immunoglobulin G. The kinetics of dissociation, studied by the Scatchard analysis of the autoantibody, showed a curvilinear plot, which was analyzed in two components. Cold human insulin was able to compete with 125I-insulin for the antibody binding site (I.C.50 = 1.35 nmol/ml). These antibodies were apparently not associated with antibodies directed against the insulin receptor.
Collapse
Affiliation(s)
- A Di Cerbo
- Divisione di Endocrinologia, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | | | | | | | | |
Collapse
|
25
|
Affiliation(s)
- V Marks
- School of Biological Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
26
|
Affiliation(s)
- V Marks
- Department of Clinical Biochemistry and Nutrition, St Luke's Hospital Guildford, Surrey, U.K
| | | |
Collapse
|
27
|
Chuah SY, Lyne AJ, Dronfield MW. Vogt-Koyanagi-Harada syndrome, a rare association of Hodgkin's disease. Postgrad Med J 1991; 67:476-8. [PMID: 1852672 PMCID: PMC2398862 DOI: 10.1136/pgmj.67.787.476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Vogt-Koyanagi-Harada syndrome (VKHS) is a well-documented clinical entity. We report the case of a 24 year old man who, within 5 months of the diagnosis of VKHS, developed Hodgkin's disease. Like VKHS, the aetiology of Hodgkin's disease is unknown. A viral factor has been suspected in the pathogenesis of both conditions. Similar immunological abnormalities have been described in both, and may be important predisposing factors.
Collapse
Affiliation(s)
- S Y Chuah
- Department of Medicine, Peterborough District Hospital, Cambridgeshire, UK
| | | | | |
Collapse
|
28
|
Gambhir KK, Agarwal VR. Red blood cell insulin receptors in health and disease. BIOCHEMICAL MEDICINE AND METABOLIC BIOLOGY 1991; 45:133-53. [PMID: 1883623 DOI: 10.1016/0885-4505(91)90015-d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTENTS Structure and characteristics of erythrocyte insulin receptor. Red blood cell age and insulin receptors. Insulin receptors in human disease states. Obesity. Chronic renal failure. Acanthosis nigricans. Miscellaneous disease states. Insulin receptors in children. Insulin receptors in women during pregnancy. Insulin binding and other hormones. Comparison of biosynthetic insulin, pancreatic human insulin and porcine insulin binding to erythrocytes. Effect of exercise on insulin binding to red blood cells of normal human volunteers. Miscellaneous insulin binding studies. Insulin internalization and degradation. Insulin and erythrocyte metabolism. Summary and conclusion.
Collapse
Affiliation(s)
- K K Gambhir
- Department of Medicine, College of Medicine, Howard University, Washington, DC 20059
| | | |
Collapse
|
29
|
De Pirro R, Borboni P, Marini MA, Montemurro A, Sesti G, Lauro R. Antibodies directed to the insulin receptor. Clinical aspects and applications to the study of insulin action. J Endocrinol Invest 1990; 13:951-68. [PMID: 2090677 DOI: 10.1007/bf03349669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- R De Pirro
- Cattedra di Endocrinologia, Università di Ancona, Italy
| | | | | | | | | | | |
Collapse
|
30
|
Affiliation(s)
- J C Chan
- Department of Medicine, Chinese University of Hong Kong
| | | | | | | |
Collapse
|
31
|
Rochet N, Sadoul JL, Ferrua B, Kubar J, Tanti JF, Bougnères P, Vialettes B, Van Obberghen E, Le Marchand-Brustel Y, Freychet P. Autoantibodies to the insulin receptor are infrequent findings in type 1 (insulin-dependent) diabetes mellitus of recent onset. Diabetologia 1990; 33:411-6. [PMID: 2205528 DOI: 10.1007/bf00404090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To determine whether autoantibodies to the insulin receptor may represent markers of Type 1 (insulin-dependent) diabetes, the prevalence of such antibodies was investigated in sera of 60 newly diagnosed untreated Type 1 diabetic patients. A sensitive assay, based on enzyme linked immunosorbent assay has been set up which detects antibodies to the insulin receptor irrespective of their potentially inhibiting effect on insulin binding. Moreover, this method allows easy determination of the immunoglobulin class involved in the anti-receptor activity. Among the 60 sera examined, only one was found to contain anti-insulin receptor autoantibodies (IgG class). In view of our data, we conclude that autoantibodies to the insulin receptor are infrequent findings in Type 1 diabetes of recent onset.
Collapse
Affiliation(s)
- N Rochet
- INSERM U 145, Faculté de Médecine, Nice, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
The issue of the peripheral resistance to insulin action has been getting a lot of attention over the last decade. The reason for this is that insulin is a major regulatory hormone and is involved in the metabolism of carbohydrates, lipids, protein and ions. To understand the pathophysiology of insulin resistance it is necessary to elucidate the methods for the assessment of insulin resistance and the molecular mechanism of insulin action. Insulin action is impaired in pathologic and physiologic states such as diabetes mellitus and obesity as well as in some rare syndromes. Further understanding of the pathophysiology of the impaired action of insulin improves the chances of defining new ways of treatment to improve the sensitivity to insulin action.
Collapse
Affiliation(s)
- M Koffler
- University of Texas Southwestern Medical Center, Department of Internal Medicine, Dallas 75235
| | | | | |
Collapse
|
33
|
Rochet N, Blanche S, Carel JC, Fischer A, Deist FL, Griscelli C, Van Obberghen E, Le Marchand-Brustel Y. Hypoglycaemia induced by antibodies to insulin receptor following a bone marrow transplantation in an immunodeficient child. Diabetologia 1989; 32:167-72. [PMID: 2546845 DOI: 10.1007/bf00265089] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Severe hypoglycaemia developed seven months after a bone marrow transplantation in a child with severe combined immunodeficiency. His serum exerted potent insulin-like activity: (a) it stimulated insulin receptor autophosphorylation and kinase activity in cell-free systems, this effect being additive to insulin; (b) it increased glucose transport in isolated soleus muscle. These insulin-like effects were due to immunoglobulins against the insulin receptor. Indeed, the patient serum immunoprecipitated human or murine insulin receptors from different tissues and inhibited insulin binding to receptor on human IM-9 lymphocytes. After corticoids and immunosuppressive therapy by azathioprine, the patient hypoglycaemic episodes disappeared, and concomitantly, the antibodies to insulin receptor were no longer detected, as judged by both immunoprecipitation of insulin receptor and stimulation of glucose transport.
Collapse
Affiliation(s)
- N Rochet
- INSERM U145, Faculté de Médecine, Nice, France
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
Acanthosis nigricans is a marker for disorders of insulin action, endocrine abnormalities, and cancer of internal organs. To evaluate the clinical significance of this marker the systemic alterations and clinical features of 26 patients with acanthosis nigricans seen at two institutions were reviewed. Most subjects affected by acanthosis nigricans were female (20 patients), Caucasian (22 patients), in the third decade of life (13 patients), and overweight (24 patients greater than 120 percent ideal body weight). Gonadal disease, present in 17 patients, was expressed as polycystic ovary syndrome (11 cases), disorders of prolactin secretion (two cases, one with polycystic ovary syndrome), streak gonads (one case), and hypogonadism of the male (four cases). Thyroid disease and tinea versicolor were present in four patients each. Three patients were receiving insulin therapy for diabetes mellitus, and in two additional patients diabetes mellitus was detected during the diagnostic workup. All patients had elevated fasting insulin levels; most of them also had an exaggerated insulin response to a glucose load. Two of 18 patients tested had antibodies against the insulin receptor in the circulation. Skin biopsy of acanthosis nigricans lesions from all 26 patients showed a typical pattern of hyperkeratosis, acanthosis, and epidermal papillomatosis. Colloidal iron staining showed glycosaminoglycan infiltration of the papillary dermis (21 of 21 cases), consisting mainly of hyaluronic acid. It is concluded that: (1) hyperinsulinenemia and local dermal glycosaminoglycan deposition are regular features in acanthosis nigricans and (2) patients with acanthosis nigricans should be screened for diabetes mellitus, gonadal disease, and hypothyroidism.
Collapse
Affiliation(s)
- L Y Matsuoka
- Department of Medicine, Southern Illinois University, Springfield 62794-9230
| | | | | | | |
Collapse
|