Endocrine Abstracts

Introduction: Exogenous insulin antibodies syndrome (EIAS) is a clinical syndrome associated with insulin antibodies induced by exogenous insulin in diabetic patients. It represents a rare cause of hyperinsulinemic hypoglycemia and glycemic instability. The management of EIAS remains a challenge.

Case presentation: We present the case of a 12-year-old female with type 1 diabetes for 6 years treated with insulin analogues (Glrargen and Aspart). She experienced significant glycemic instability, leading to frequent hospitalizations for diabetic ketosis and ketoacidosis with no apparent cause, resulting in an average HbA1c of 14%. Her mother reported discontinuation of rapid insulin due to recurrent hypoglycemia. The patient weighed 32 kg, had a height of 145 cm (-2DS), and investigations revealed an isolated growth hormone deficiency. The anti-exogenous insulin antibody titer was elevated at 24 UI/ml (VN <0.4). Treatment with a high dose of corticosteroids (30g of prednisolone) resulted in a favorable response, marked by a significant improvement in glucose stability and no unexplained hypoglycemia. Corticosteroids were maintained for 4 months and then gradually tapered. However, after discontinuation, a recurrence of glycemic instability was observed.

Discussion: EIAS typically manifests months or years after initiating insulin treatment and can affect both type I and II diabetes patients. It is a rare cause of glycemic instability, characterized by daytime hyperglycemia due to insulin uptake by anti-insulin antibodies and nocturnal hypoglycemia due to insulin release. The initial treatment of EIAS involves glucocorticoids. In our case, we initiated treatment with 2 UI/kg of prednisolone for 4 months, with a gradual dose reduction. The literature suggests alternative treatments, including oral or IV immunosuppression such as mycophenolate mofetil, cyclophosphamide, and azathioprine, although outcomes vary. Plasmapheresis can serve as effective therapy in patients who are refractory to other therapeutic modalities based on the results of literature review and case reports.

Conclusions: EIAS should be considered in T1D patients with unexplained glycemic instability and hypoglycemia. The laboratory plays an integral diagnostic role. The management of EIAS is poorly codified. Longer-term follow-up is necessary, as recurrence is classic in this type of pathology