Hyperinsulinemic hypoglycemia associated with insulin antibodies caused by exogenous insulin analog. (17th November 2016)

• Record Type: Journal Article
• Authors: Su, Chih-Ting; Lin, Yi-Chun
• Is Part Of: Endocrinology, diabetes & metabolism case reports. (2016)
• Publication Date: 2016-11-17
• Subjects: Adult -- Male -- Asian - Chinese -- Taiwan, Province of China; Pancreas -- Diabetes -- Insulin -- Hyperinsulinaemia -- Hypoglycaemia -- Hypoglycaemic coma -- Diabetes mellitus type 1; Hypoglycaemia -- Hyperinsulinaemia -- Diabetes mellitus type 1 -- Altered level of consciousness -- Coma -- Syncope -- Insulin -- Insulin (fasting) -- Glucose (blood) -- Glucose tolerance (oral) -- C-peptide (blood) -- Glucose (blood, fasting) -- Cortisol (serum) -- Anti-insulin antibodies -- Prednisolone -- Glucocorticoids -- Insulin glargine -- Insulin; Unique/unexpected symptoms or presentations of a disease -- November -- 2016; Endocrinology -- Periodicals; Diabetes -- Periodicals; Diabetes Mellitus; Endocrinology; Diabetes; Endocrinology; Case Reports; Periodicals; Periodicals; 616.4
• DOI: 10.1530/EDM-16-0079
• Languages: English
• ISSNs: 2052-0573

Abstract

Summary: Insulin antibodies (IA) associated with exogenous insulin administration seldom caused hypoglycemia and had different characteristics from insulin autoantibodies (IAA) found in insulin autoimmune syndrome (IAS), which was first described by Dr Hirata in 1970. The characteristic of IAS is the presence of insulin-binding autoantibodies and related fasting or late postprandial hypoglycemia. Here, we report a patient with type 1 diabetes mellitus under insulin glargine and insulin aspart treatment who developed recurrent spontaneous post-absorptive hyperinsulinemic hypoglycemia with the cause probably being insulin antibodies induced by exogenous injected insulin. Examinations of serial sera disclosed a high titre of insulin antibodies (33%, normal <5%), high insulin concentration (111.9 IU/mL) and undetectable C-peptide when hypoglycemia occurred. An oral glucose tolerance test revealed persistent high serum levels of total insulin and undetectable C-peptide. Image studies of the pancreas were unremarkable, which excluded the diagnosis of insulinoma. The patient does not take any of the medications containing sulfhydryl compounds, which had been reported to cause IAS. After administering oral prednisolone for 3 weeks, hypoglycemic episodes markedly improved, and he was discharged smoothly. Learning points: Insulin autoimmune syndrome (IAS) or IAS-like situation should be one of the differential diagnosis in patients with hyperinsulinemic hypoglycemia. Although less reported, insulin antibodies (IA) caused by exogenous insulin analog should be considered as the cause of hypoglycemia. Patients with suspected insulin autoimmune syndrome (IAS) should be screened for drugs related to autoimmunity to endogenous insulin.