Case Report: Insulin hypersensitivity in youth with type 1 diabetes

Objective

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

Methods

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

Results

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

Conclusion

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

Modulation of mouse sperm-egg interaction, early embryonic development and trophoblastic outgrowth by activated and unactivated macrophages

Exposure of mouse spermatozoa and oocytes duringin vitro fertilization (IVF) to lipopolysaccharide (LPS) and phorbol myristate acetate (PMA) activated macrophages (U937 cell line), but not unactivated macrophages cultureconditioned medium or control medium (RMPI+DMEM with 0.5% FBS) resulted in inhibition of IVF (87.2%), first cleavage (90.8%) and total blastocyst formation 97.5%). The direct coculture of the activated macrophages with 2-cell stage embryos resulted in arrested development (91.2%), an effect that was significantly diminished in the presence of monolayer of human endometrial stromal cells in the coculture (58.3%). In contrast, the majority of 2-cell embryos developed to blastocysts when exposed to unactivated macrophages, or macrophage-stromal cell cocultures (94.1%). The majority of 2-cell embryos cultured in control medium (DMEM/Ham's F12 with 2% FBS) developed to morulae (96.2%), then underwent growth arrest and degeneration. Furthermore, culturing blastocyst stage embryos in the above groups resulted in a significant enhancement of trophoblast outgrowth, particularly in coculture with activated macrophages as compared to any other group (P<0.005). There was a significant increase in the levels of TGF-β, GM-CSF, IL-1α, IL-1β, TNF-α, PGE(2), TXB(2) and LTB(4) released into the culture conditioned medium of activated macrophages compared to unactivated macrophages (P<0.001). These results suggest that the secretory products of activated macrophages, among them those determined in this study, in a stage-specific manner can directly effect sperm-egg interaction, early embryonic development and trophoblastic outgrowth. This data provides further support for the hypothesis that in endometriosis-associated infertility, continuous exposure of spermatozoa, oocytes and early embryos to activated macrophage-derived factors may play a vital role in their survival during transportation and fertilization as well as development during early embryonic stage.

Immunohistochemical localization of insulin-like growth factor (IGF-I), IGF-I receptor, and IGF binding proteins 1-4 in human fallopian tube at various reproductive stages

Despite the existence of numerous data regarding the insulin-like growth factor (IGF) system in reproductive tissues, especially uterine and ovarian, very little information is available concerning their presence in oviductal/fallopian tube tissue. To elucidate this, the present study was undertaken to determine the presence and cellular distribution of IGF-I, IGF-I receptor (IGF-IR), and IGF binding proteins (IGFBP) 1-4 in human fallopian tubes during various reproductive stages, by means of immunohistochemical analysis with specific antibodies to IGF-I, IGF-IR and IGFBPs 1-4. The primary site of immunoreactivity for these proteins in fallopian tube tissue was in the epithelial lining of the tubes, with substantially lower intensity in the smooth muscle layer, fibroblasts of the serosal tissue, and arteriolar endothelial and smooth muscle cells. The immunostaining was associated with both ciliated and nonciliated tubal epithelial cells without substantial differences in their intensity. There were also no differences in immunoreactivity of IGF-I, IGF-IR, and IGFBPs 1-4 present in ampullary vs. isthmus region of the tubes. Specimens obtained 5-12 years post tubal ligation stained similarly to sections from unligated tubes taken during the same phase of the cycle. The intensity of immunostaining for the IGFBPs was greatest for IGFBP-1, followed by IGFBP-4, then IGFBP-2 and IGFBP-3, with 2 and 3 having similar intensities. The immunostaining intensity of IGF-I, IGF-IR, and IGFBPs in fallopian epithelial cells was cycle-dependent and considerably higher in late proliferative and early-mid secretory compared to late secretory phases, with little immunostaining in the early proliferative phase of the menstrual cycle and postmenopausal period. In summary, the immunohistochemical study reported here demonstrates the presence of IGF-I, IGF-IR, and IGFBPs 1-4 in the human fallopian tube during various reproductive stages. These data suggest an autocrine/paracrine role for the IGF-I system in fallopian tube function, and their cyclic dependency further implies ovarian steroidal regulation.