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Insulin Autoimmune Hypoglycemia

Insulin Autoimmune Syndrome As A Cause Of Recurrent Hypoglycemia In A Carbimazole User: A Case Report From Nepal

Insulin Autoimmune Syndrome As A Cause Of Recurrent Hypoglycemia In A Carbimazole User: A Case Report From Nepal

Editor who approved publication: Professor Ronald Prineas Vivek Pant,1 Bijay Bhandari,2 Suman Baral,3 Sangha Ratna Bajracharya4 1Department of Clinical Biochemistry, Institute of Medicine (IOM), Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal; 2Department of Clinical Pharmacology, Institute of Medicine (IOM), Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal; 3Endocrine Unit, Department of Medicine, Institute of Medicine (IOM), Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal; 4Department of Clinical Pharmacology, Institute of Medicine (IOM), Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal Abstract: Insulin autoimmune syndrome (IAS) is a rare cause of nondiabetic hypoglycemia characterized by hyperinsulinemia and autoantibodies to endogenous insulin without prior exposure to exogenous insulin. We report a drug-induced case of IAS in a 59-year-old Nepalese female. She had been taking carbimazole for Graves disease and later presented with recurrent episodes of hypoglycemia, with laboratory findings of low blood glucose, increased molar ratio of insulin to C-peptide, and elevated autoantibodies to insulin. IAS should be considered while evaluating hypoglycemia to prevent unwarranted invasive procedures and surgical interventions. Keywords: insulin autoimmune syndrome, hypoglycemia, carbimazole, Hirata disease This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License . By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed Continue reading >>

Insulin Autoimmune Syndrome: A Rare Cause Of Hypoglycaemia Not To Be Overlooked - Em|consulte

Insulin Autoimmune Syndrome: A Rare Cause Of Hypoglycaemia Not To Be Overlooked - Em|consulte

INSULIN AUTOIMMUNE SYNDROME: A RARE CAUSE OF HYPOGLYCAEMIA NOT TO BE OVERLOOKED M.L. Virally[1], J. Timsit[2], Ph. Chanson[3], A. Warnet[1], P.J. Guillausseau[1] [1]Service de Mdecine B, Hpital Lariboisire et Facult de Mdecine Lariboisire-Saint-Louis, 2, rue Ambroise Par, 75010 Paris, France. [2]Service d'Immunologie clinique, Hpital Necker, 149, rue de Svres, 75016 Paris, France. [3]Service d'Endocrinologie, Hpital Bictre, 78, rue du gnral Leclerc, 94272 Le Kremlin-Bictre, France. We report the case of a Caucasian patient with insulin autoimmune syndrome (IAS), defined as the association of hypoglycaemic attacks with insulin autoantibodies in individuals not previously treated with exogenous insulin. This rare syndrome (more than 200 published cases) has been reported mainly in Japan. Most affected patients present with other autoimmune disorders, most often Graves' disease. In most cases, insulin autoantibodies appear a few weeks after the beginning of treatment with a drug containing a sulphyldryl group. A significant increase in insulin and C-peptide plasma concentrations and the presence of other antiorgan antibodies are observed. The susceptibility haplotype is present in the Japanese population, which may account for the high frequency of IAS. Spontaneous remission is observed in 80 % of cases, with cessation of hypoglycaemic attacks and disappearance of insulin autoantibodies some months after withdrawal of the drug. This rare cause of hypoglycaemia in Caucasian subjects should be considered in aetiologic investigation of spontaneous hypoglycaemia. Hypoglycmie par auto-anticorps anti-insuline: une cause rare d'hypoglycmie ne pas mconnatre Nous rapportons le cas d'un patient caucasien prsentant une hypoglycmie par auto-anticorps anti-insuline. Ce syndrome associ Continue reading >>

Insulin Autoimmune Syndrome Mimicking Insulinoma: A Challenging Diagnosis Abstract #547

Insulin Autoimmune Syndrome Mimicking Insulinoma: A Challenging Diagnosis Abstract #547

Insulin Autoimmune Syndrome Mimicking Insulinoma: A Challenging Diagnosis Introduction: Insulin autoimmune syndrome (IAS) is a rare condition characterized by hypoglycemia due to autoantibodies against endogenous insulin. It is correlated, in approximately 50% of cases, to specific drugs intake. Hypoglycemia occurs typically during the late post-prandial period. Aim(s): We report two cases of IAS patients who came to our attention because of recurrent and severe hypoglycemia. Materials and methods: Case 1: A 29-year-old female, affected by Graves disease and treated with methimazole, was evaluated in 2006 because of recurrent hypoglycemia. Insulinemia was >1000 UI/ml. Fasting test was negative as well as abdomen MRI. After total thyroidectomy glycemic and insulin levels normalized. Case 2: A 45-year-old female came to our attention in 2011 because of recurrent post-prandial hypoglycemia. Insulinemia was >1000 UI/ml. An OGTT revealed late reactive hypoglycemia, while fasting test was normal as well as EUS. Dosing of insulin antibodies was 658 U/ml (<0.4). With an adequate diet and acarbose treatment the symptoms improved. Conference: 9th Annual ENETS Conference (2012) Presenting Author: Prof Laura De Marinis Continue reading >>

Insulin Autoimmune Syndrome: From Diagnosis To Clinical Management

Insulin Autoimmune Syndrome: From Diagnosis To Clinical Management

Insulin autoimmune syndrome: from diagnosis to clinical management Insulin autoimmune syndrome: from diagnosis to clinical management Authors: Simona Censi, Caterina Mian, Corrado Betterle 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 Hiratas disease. The other is type B insulin resistance syndrome (TBIRS), a rare autoimmune disorder resulting in a broad array of abnormalities in glucose homeostasisfrom hypoglycemia to extremely insulin-resistant hyperglycemiacaused 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. Continue reading >>

A Rare Cause Of Hypoglycemia: Insulin Autoimmune Syndrome In A Turkish Patient Taking Alpha Lipoic Acid

A Rare Cause Of Hypoglycemia: Insulin Autoimmune Syndrome In A Turkish Patient Taking Alpha Lipoic Acid

Endocrine Abstracts (2018) 56 P325 | DOI: 10.1530/endoabs.56.P325 A rare cause of hypoglycemia: insulin autoimmune syndrome in a Turkish patient taking Alpha lipoic acid Basak Bolayir1, Mehmet Ayhan Karakoc1, Muzaffer Serdar Deniz1, Alev Altinova1, Mujde Akturk1, Busra Yurumez2, Fusun Toruner1 & Ilhan Yetkin1 1Department of Endocrinology and Metabolism, Gazi University Faculty of Medicine, Ankara, Turkey; 2Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey. Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia and characterized with autoantibodies to insulin in a patient without prior exposure to exogenous insulin. Medications with sulfydryl group and autoimmune diseases are known to be associated with this syndrome. Nearly 90% of the cases were reported in Japanese patients. We presented a Turkish patient with inslin autoimmune syndrome possibly caused by -lipoic acid. A 62-year-old woman was admitted to our clinic recurrent episodes of sweating, weariness, heart palpitations and anxiety occurring both fasting and postprandial. The first episode was two weeks before admission and the capillary glucose was measured as 40 mg/dl during episode. She had been diagnosed with hypertension and hyperlipidemia for ten years and treated with indapamid, nebivolol and atorvastatin. She had never been diagnosed as diabetes mellitus and never injected insulin before. She had no family history of diabetes or autoimmune disease. She had been taken multivitamin preparation which contained -lipoic acid until three weeks prior to her hospitalization. Laboratory investigations revealed normal renal and liver functions. During hypoglycemic event, serum glucose was 46 mg/dl; serum insulin was 1890 IU/ml (normal: 1.9-23) and C-peptide was 11.9 ng Continue reading >>

Insulin Autoimmune Syndrome In A Pregnant Female: A Rare Case Report

Insulin Autoimmune Syndrome In A Pregnant Female: A Rare Case Report

Insulin autoimmune syndrome (IAS) was first reported in Tohoku Journal of Experimental Medicine in the 1970s by Hirata et al. [1] The first case report in China appeared in the Chinese Journal of Endocrinology and Metabolism in 1986 of a 49-year-old man with Graves disease who was treated with methimazole for 1 month and experienced severe spontaneous hypoglycemia. [2] IAS occurs when the titer of anti-insulin autoantibodies and immune reactive insulin increases causing transformation from benign autoimmunity to pathogenic autoimmunity. [3] This progression is determined by both genetic influences and environmental triggers such as medication, genetic instability, and other factors. [3] It is considered that IAS is associated with genetic immune deficiency, and that HLA-DR4 is the main susceptible gene (mainly with DRB1*0406 and sometimes with DRB1*0403 and DRB1*0407). [4] Patients with IAS are frequently aged >39 years with no difference between sexes. At present, there are no reports of IAS in pregnant women. IAS is the third leading cause of hypoglycemia, after insulinoma and pancreatic tumors. According to preliminary statistics, [5] between 1970 and 2013, there were up to 400 IAS case reports of which more than 200 occurred in Japan and only a few in Western countries. In addition, over 50% of patients who are diagnosed with IAS have previously received drugs containing a sulfhydryl group, such as methimazole, which has been proposed to be related to the production of insulin autoantibodies by chemical and immunological reactions with insulin molecules. [6] Unignored, pregnancy should be considered as another pathogenic factor of hypoglycemia in IAS. We report an uncommon case of a methimazole-associated IAS in a Chinese pregnant female patient. A 26-year-old Chin Continue reading >>

Hypoglycemia Due To Insulin Autoimmune Syndrome: A Rare Cause Not To Be Forgotten

Hypoglycemia Due To Insulin Autoimmune Syndrome: A Rare Cause Not To Be Forgotten

Highlights • Insulin Autoimmune Syndrome (IAS) is a rare cause of hypoglycemia. • Most cases of IAS have been reported from Japan and this is the fourth case from India. • It should be considered among the differential diagnosis of hypoglycemia to avoid unnecessary investigations and surgery. • It runs a benign course and can be managed on a diet of frequent small meals and withdrawal of offending drugs. Most cases of recurrent hypoglycemia occur in patients with diabetes mellitus and can be prevented by changes in medications, diet or activity. However, a person with unexplained hypoglycemia can indicate potentially grave, often treatable underlying disorders such as insulinoma, Addison's disease or hypopituitarism. Medication is another cause of unexplained hypoglycemia. A focused laboratory work-up is essential, often a plasma/serum glucose, insulin and C-peptide. Normal or high insulin and C-peptide levels indicate excessive endogenous insulin production. We are reporting a case of Insulin Autoimmune Syndrome (IAS) in a 38-year-old Indian female who presented to us with recurrent episodes of spontaneous hypoglycemia. On evaluation, the patient was found to have Endogenous Hyperinsulinemic Hypoglycemia (EHH). As no obvious cause of EHH was found on abdominal imaging, we further evaluated her for insulin antibodies which were found to be raised. A diagnosis of IAS was made and the patient was put on a diet of frequent small meals and she improved. Most cases of this syndrome have been reported from Japan and very few case reports of IAS exist in India. Thus IAS, though rare, should be kept in the differential diagnosis of spontaneous hypoglycemia. Continue reading >>

(pdf) Hypoglycemia Due To Insulin Autoimmune Syndrome: A Rare Cause Not To Be Forgotten

(pdf) Hypoglycemia Due To Insulin Autoimmune Syndrome: A Rare Cause Not To Be Forgotten

To appear in: Journal of Clinical and Translational Endocrinology: Case Reports Please cite this article as: Sarah Alam, Maaz Ozair, Jamal Ahmad, Hypoglycemia due to insulin autoimmune syndrome: A rare cause not to be forgotten, Journal of Clinical and Translational Endocrinology: Case Reports (2016), 10.1016/j.jecr.2016.05.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Hypoglycemia due to Insulin Autoimmune Syndrome: A rare cause not to Insulin Autoimmune Syndrome (IAS) is a rare cause of hypoglycemia. Most cases of IAS have been reported from Japan and only three published case reports from India. To the best of our knowledge, this is the fourth case of IAS It should be considered among the differential diagnosis of hypoglycemia to avoid It runs a benign course and can be managed on a diet of frequent small meals and Most cases of recurrent hypoglycemia occur in patients with diabetes mellitus and can be prevented by changes in medications, diet or activity. However, a person with unexplained hypoglycemia can indicate a potentially grave, often treatable underlying disorders such as insulinoma, addisons disease or hypopituitarism. Medication is another cause of unexplained hypoglycemia. A focussed laboratory work-up is essential; often a plasma/serum glucose, insulin and C-peptide. Normal or high insulin and C-peptide levels indicate excessive endogeno Continue reading >>

Autoimmune Hypoglycemia In A Type 2 Diabetic Patient With Anti-insulin And Insulin Receptor Antibodies

Autoimmune Hypoglycemia In A Type 2 Diabetic Patient With Anti-insulin And Insulin Receptor Antibodies

There are two types of autoimmune hypoglycemia, one due to autoantibodies acting against the insulin receptor and the other due to autoantibodies acting against insulin itself in individuals who have or have never received exogenous insulin, respectively (1). Both types are rare and can produce fasting and postprandial reactive hypoglycemia. A 72-year-old woman with frequent severe hypoglycemia was admitted to the emergency room, presenting with loss of consciousness. Three weeks before her admission, she was diagnosed with diabetes and received insulin at a local hospital. In the emergency room, her blood glucose level was 40 mg/dl. She had been in good general health, except for hypertension for 30 years and postmenopausal osteoporosis 10 years before admission. She has no evidence of other diseases associated with altered immunity. Three weeks ago, her biceps tendon ruptured when she slipped and fell, and during treatment, her blood glucose levels were >400 mg/dl. She was treated with insulin. However, she stopped insulin treatment because of frequent hypoglycemic events. Although she had had intravenous glucose injections, she had frequent hypoglycemic attacks, such as disorientation, loss of consciousness, palpitation, and diaphoresis. Her blood glucose levels had been <40 mg/dl on every hypoglycemic event, especially during fasting hypoglycemia. Physical examination revealed normal vital signs except for a chronically ill appearance. Her HbA1c was 6.3% (range 3–6%), plasma glucose 40 mg/dl, insulin 103.7 μU/ml, C-peptide 4.1 ng/ml, GAD autoantibody levels 0.01 units/ml (normal range 0–1.45 units/ml; RSR, Cardiff, U.K. ), and insulinoma-associated protein 2 autoantibody 0.01 units/ml (normal range 0–1.1 units/ml; RSR). Her thyroid, liver, and adrenal functio Continue reading >>

Rare Cause Of Recurrent Hypoglycemia: Insulin Autoimmune Syndrome

Rare Cause Of Recurrent Hypoglycemia: Insulin Autoimmune Syndrome

Rare Cause of Recurrent Hypoglycemia: Insulin Autoimmune Syndrome Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Correspondence should be addressed to Apiradee Sriwijitkamol Received 19 July 2017; Accepted 18 September 2017; Published 26 November 2017 Copyright 2017 Rungsima Tinmanee et al. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We report a case of insulin autoimmune syndrome associated with several autoantibodies, presenting with recurrent hypoglycemia, predominantly in the postprandial period, which improved by dietary management and spontaneously resolved within two months. Differentiation from other causes of hyperinsulinemic hypoglycemia, such as insulinoma, is important to avoid unnecessary invasive procedures or surgical interventions. The 75-gram oral glucose tolerance test (OGTT) and mixed meal test showed a typical pattern, which may be useful indirect evidence of insulin autoimmune syndrome. Insulin autoimmune syndrome (IAS) or Hirata disease, a rare cause of hyperinsulinemic hypoglycemia first described by Hirata et al. in 1970 [ 1 ], is characterized by concurrent hypoglycemia with a very high insulin level and the presence of insulin autoantibodies in insulin-nave patients [ 2 ]. Several autoimmune diseases, predominantly Graves disease, are associated with insulin autoimmune syndrome [ 3 5 ]. A 74-year-old previously healthy woman was referred to our hospital due to palpitation and sweating for one month. She did not take any medication. Her first episode of palpitation, sweating, and sl Continue reading >>

Insulin Antibodies

Insulin Antibodies

Antibodies to exogenously delivered insulin are common with insulin treatment but are not often clinically significant. IgG antibodies are the most common while IgE antibodies are the cause of insulin allergy[10]. At high titers, IgG antibodies may limit insulin action which could delay or diminish insulin action. Rarely, antibodies can be agonists to the insulin receptor and cause hypoglycemia (usually postprandial hypoglycemia)[11]. The development of antibodies depends on the purity, molecular structure, and storage conditions of the insulin administered as well as patient factors such as age, HLA type, and delivery route[10]. Most common when patients are exposed to beef or pork insulin, rather than only to human or analog insulins[9]. Insulin auto-antibodies, in people not previously treated with insulin, are an indication of developing type 1 diabetes (See Insulin Initiation in Type 1 Diabetes and to LADA for more information). React equally to analog insulin and unmodified human insulins. Radioligand binding (RLB) assays are the most common assay used for measurement of insulin antibodies[10]. Standard immunoprecipitation and agglutination analytic methods cannot measure insulin antibodies since insulin antibody immune complexes do not precipitate[10]. High sensitivity is required for evaluating autoantibodies, which are in much lower concentration than antibodies to exogenous insulin[13]. Gel filtration chromatography can identify insulin immunocomplexes with addition of exogeneous insulin to diagnose insulin autoimmune syndrome without necessarily using radiolabelled reagants[1]. The presence of insulin antibodies does not prove that they are causing insulin resistance or hypoglycemia. More soluble insulins, such as regular and semilente are less allergenic tha Continue reading >>

Recurrent Hypoglycemia From Insulin Autoimmune Syndrome

Recurrent Hypoglycemia From Insulin Autoimmune Syndrome

Go to: CASE REPORT A 45-year-old Caucasian woman presented to clinic with a 6-week history of recurrent hypoglycemic symptoms consisting of fatigue, lightheadedness, blurry vision, and diaphoresis. The episodes were triggered by fasting and exercise, and alleviated with food intake. She also reported a 10-pound weight gain during this period. There was no history of diabetes mellitus in the patient or her family, and she had no access to insulin and/or insulin secretagogues. Past medical history was significant for endometriosis requiring multiple pelvic surgeries, von Willebrand disease, hepatic steatosis, gastroesophageal reflux disease, and patellofemoral syndrome. The patient took esomeprazole occasionally but no other prescription or over-the-counter medications. She did not smoke, drink alcohol, or use recreational drugs. Family history was negative for any endocrine tumors or autoimmune diseases. Vital signs were normal and her physical examination was non-contributory. Laboratory investigations revealed normal renal and liver function. Hemoglobin A1c was 5.4 %. Adrenocorticotropic hormone (ACTH) stimulation test indicated an adequate cortisol response. Blood work was collected during a spontaneous symptomatic hypoglycemic event (Table 1). The markedly increased insulin level and the non-suppressed connecting peptide (C-peptide) result, along with the corresponding insulin to C-peptide molar ratio of 13.4, were incompatible with exogenous insulin administration as the cause of hypoglycemia. Computed tomography (CT) of the abdomen did not identify any masses in the pancreas or in the retroperitoneum. Magnetic resonance imaging (MRI) of the abdomen was aborted due to feelings of claustrophobia in the patient. Selective arterial calcium stimulation was performed to Continue reading >>

Insulin Autoimmune Syndrome

Insulin Autoimmune Syndrome

Insulin autoimmune syndrome is a rare condition that causes low blood sugar (hypoglycemia). This occurs because the body begins to make a specific kind of protein called antibodies to attack insulin. Insulin is a naturally occurring hormone that is responsible for keeping blood sugar at a normal level. When blood sugar levels get too high, insulin helps to store the sugar for future use. People affected by insulin autoimmune syndrome have antibodies that attack insulin, causing it to work too hard and the level of blood sugar to become too low. Insulin autoimmune syndrome most often begins during adulthood.[1][2] Insulin autoimmune syndrome occurs suddenly as antibodies are produced that attack the insulin which the body is producing naturally. Because a person affected by this condition is producing antibodies to attack a naturally occurring substance, the condition is classified as a type of autoimmune syndrome. This means that the immune system, which is responsible for protecting the body from disease, is instead attacking the body itself.[1] Exactly why these antibodies against insulin are suddenly produced can vary from person to person. In some cases, insulin autoimmune syndrome occurs in a person with another autoimmune disease, which can indicate that the immune system in the body is not behaving correctly. Additionally, a certain class of medications called sulphydryl compounds have been shown to sometimes cause insulin autoimmune syndrome. Some of these medications are used to treat other autoimmune conditions. Recently, a compound called alpha-lipoic acid has been associated with an increased risk of developing insulin autoimmune syndrome. This compound is sometimes used for dieting purposes.[5] Support and advocacy groups can help you connect with other pat Continue reading >>

Novel Management Of Insulin Autoimmune Syndrome With Rituximab And Continuous Glucose Monitoring

Novel Management Of Insulin Autoimmune Syndrome With Rituximab And Continuous Glucose Monitoring

Novel Management of Insulin Autoimmune Syndrome with Rituximab and Continuous Glucose Monitoring Division of Endocrinology, Metabolism, and Diabetes (D.R.S., M.T.M.), University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045 Research Service (D.R.S.), Denver Veterans Affairs Medical Center, Denver, Colorado 80220 Address all correspondence and requests for reprints to: David Saxon, MD, University of Colorado School of Medicine, Division of Endocrinology, Metabolism, and Diabetes, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045. Search for other works by this author on: Division of Endocrinology, Metabolism, and Diabetes (D.R.S., M.T.M.), University of Colorado, Anschutz Medical Campus, Aurora, Colorado 80045 Search for other works by this author on: Barbara Davis Center for Childhood Diabetes (A.W.M.), Anschutz Medical Campus, Aurora, Colorado 80045 Search for other works by this author on: The Journal of Clinical Endocrinology & Metabolism, Volume 101, Issue 5, 1 May 2016, Pages 19311934, David R. Saxon, Michael T. McDermott, Aaron W. Michels; Novel Management of Insulin Autoimmune Syndrome with Rituximab and Continuous Glucose Monitoring, The Journal of Clinical Endocrinology & Metabolism, Volume 101, Issue 5, 1 May 2016, Pages 19311934, Insulin autoimmune syndrome (IAS), or Hirata's disease, is a rare hypoglycemic disorder characterized by spontaneous hypoglycemia without evidence of exogenous insulin administration, a high serum concentration of total immunoreactive insulin, and the presence of insulin autoantibodies in high titer. The majority of cases occur in the Asian population, and treatment is generally successful with watchful waiting or steroids. We report the case of a 71-year-old Caucasian man with severe hypoglycemia due to IAS t Continue reading >>

Insulin Autoimmune Syndrome: A Rare Cause Of Postprandial Hypoglycemia

Insulin Autoimmune Syndrome: A Rare Cause Of Postprandial Hypoglycemia

Initial assessment of the Whipple criteria is critical to establish the clinical diagnosis of hypoglycemia accurately. Blood sugar monitoring with fingerstick blood glucose method can provide important information during hypoglycemia workup. Autoimmune hypoglycemia is a rare cause of hypoglycemia, which can be diagnosed on high index of clinical suspicion and systematic evaluation. Insulin autoimmune syndrome (IAS) a rare cause of autoimmune hypoglycemia was first described in a study by Hirata et al. in Japan in 1970 ( 1 ). It is characterized by spontaneous hypoglycemia, elevated insulin levels and elevated anti-insulin antibody levels. Typically, it is known to occur in patients exposed to insulin analogues ( 1 ). Other medications such as alpha lipoic acid ( 2 ) and sulfa-containing drugs such as procainamide, methimazole and hydralazine have also been found to be associated with IAS ( 3 ). We present a rare case of IAS in a patient with morbid obesity and prediabetes and using omeprazole. A 65-year-old Caucasian woman was referred to the endocrinology clinic with a 6-month history of recurrent symptoms (once a week) of sweating, headache and confusion occurring 2 h after meals. She reported no symptoms during fasting state. The fingerstick blood sugar readings during these symptoms were 35 mg/dL, 38 mg/dL and 48 mg/dL, which were obtained using her husbands glucometer. She was familiar with the symptoms of hypoglycemia as her husband has type 2 diabetes. She reported improvement of symptoms after intake of sugar-containing drinks. She denied using insulin, oral hypoglycemic agents, herbal substances or exercising vigorously. She has not undergone any bariatric procedure. She denied excessive alcohol intake. Her medical history was significant for morbid obesity wi Continue reading >>

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