Insulin autoimmune syndrome in an occidental woman: a case report and literature review

SUMMARY Insulin autoimmune syndrome (IAS, Hirata's disease) is a rare hypoglycemic disorder characterized by spontaneous hypoglycemia associated with extremely high circulating insulin levels and positive anti-insulin antibody results. Thus far, most cases have been reported in Asian countries, notably Japan, with few cases reported in western countries. As a possible cause, it is associated with the use of drugs containing sulfhydryl radicals, such as captopril. This report refers to a 63-year-old female Brazilian patient with a history of postprandial hypoglycemia. After extensive investigation and exclusion of other causes, her hyperinsulinemic hypoglycemia was considered to have likely been induced by captopril. Most cases of IAS are self-limiting. However, dietary management, corticosteroids, plasmapheresis, and rituximab have already been used to treat patients with IAS. In our case, after discontinuation of captopril, an initial decrease in insulin autoantibody levels was observed followed by improvement in episodes of hypoglycemia. Although it is a rare disease, IAS should be considered in the differential diagnosis of endogenous hyperinsulinemic hypoglycemia. Patients with suspected IAS must be screened for autoimmunity-related drugs for insulin. Initial clinical suspicion of IAS can avoid unnecessary costs associated with imaging examinations and/or invasive surgical procedures.

Autoinmunidad inducida por drogas: a propósito de un caso / Drug-induced auto-immunity: on account of a case

Se presenta el caso de una paciente de 35 años con antecedentes de enfermedad de Basedow-Graves, en tratamiento con propiltiouracilo (PTU), consumidora de pasta base y cocaína, que ingresa por fenómenos trombóticos en extremidades. Presenta en forma brusca falla respiratoria severa, que requiere manejo en UCI. Al laboratorio inmunológico destacan: ANA (+), AntiDNA (+), Anti-Ro (+), Anti-cardiolipinas IgG (+). Se realiza una revisión de las entidades autoinmunes más frecuentes asociadas al uso de drogas.

It presents the case of a 35-year old patient with a history of Basedow Graves disease, under treatment with Propiltiouracile (PTU), crack and cocaine user, who was admitted on thrombotic phenomena in her limbs. She presents sudden severe respiratory failure that requires handling at ICU. Under immunologic lab tests, the following stand out: ANA (+), Anti-DNA (+), Anti-Ro (+), Anti-cardiolipines IgG (+). A checkup is made of the most frequent auto-immune entities associated to drug abuse.

[ effects of excess iodine on immune system; an in-vitro study]

While iodine is an essential element for the synthesis of thyroid hormones, epidemiological studies have showed that excessive iodine intake leads to autoimmune thyroid diseases, with an unknown mechanism. Previous studies have showed disturbance in the circulating cytokines could lead to autoimmune diseases. To determine the role of iodine in cytokine production and development of thyroid autoimmune diseases, whole blood was stimulated with NaI [10 mm] and I2 [0.5 mm]. After evaluation of laboratory results of 25 healthy females [aged 40-45 years], 10 subjects with matched results were selected. Ten ml of sterile heparinized peripheral blood was taken from each subject and immediately were divided into 6 groups [control, NaI stimulated, I2 stimulated and matching groups in presence of standard stimulators [LPS 1 micro g/ml and PHA 10 micro g/ml]. Three identical sets were setup to investigate cytokine production at 24, 48, and 72 hours. All samples were incubated in-cell culture incubator [95% O2 and 5% CO2] and after elapse of appropriate time, plasma was separated from each well and kept at-70°C till the time of cytokines [IL-4, IL-10, INF-g and TGF-beta 1] analysis NaI could significantly decrease the production of TGF-beta 1 at all time points [P<0.02], while it did not affect the level of other cytokines. On the other hand, I2 significantly decreased the level of IL-4 and IL-10 [P<0.01]. In the presence of LPS/PHA, NaI also reduced the production of IL-10 [P<0.02], while I2 decreased the level of IL-4 as well as IL-10 [P<0.01]. For the first time, the results of this study indicated that high levels of NaI and I2 may reduce the level of protective cytokines in circulation Finally, since neither thyroid hormones nor thyroid gland had role in this process, it may be concluded that thyroid autoimmunity is initiated from high consumption of iodine leading to the imbalance in cytokine production

Auto-imunidade ANCA (Anticorpo Anti-Citoplasma de Neutrófilos) positiva induzida por propiltiouracil: relato de caso e revisão da literatura / Antineutrophil Cytoplasmic Antibody (Anca)-Associated autoimmune disease induced by propylthiouracil

A terapêutica com drogas antitireoidianas pode ser acompanhada de efeitos colaterais. Propiltiouracil (PTU) pode induzir vasculites anticorpo anti-citoplasma de neutrófilos (ANCA) positivas, na maioria das vezes relacionadas ao subtipo mieloperoxidase (ANCA-MPO). O nosso objetivo é relatar o caso de uma paciente com doença de Graves que desenvolveu auto-imunidade induzida por PTU, com manifestações cutâneas, pulmonares e renais, associadas à positividade do ANCA. O exame anátomo-patológico pulmonar revelou hemorragia difusa e a biópsia renal demonstrou glomeruloesclerose segmentar e focal. Foi tratada com pulsoterapia com corticóides e ciclofosfamida, com boa evolução clínica. Este caso enfatiza a necessidade de detecção e tratamento precoce deste efeito adverso relativamente raro do PTU.

Antithyroid drugs sometimes cause severe complications. Propylthiouracil (PTU) can be associated to ANCA positive vasculitis, most often related to myeloperoxidase subtype (ANCA-MPO). Our objective is to describe a female patient with Graves' disease, who developed PTU induced-autoimmune disease, with cutaneous, pulmonary, and renal lesions, associated with ANCA. Histopathological examination revealed diffuse pulmonary hemorrhage, and focal segmental glomerulosclerosis at the kidney biopsy. She was treated with systemic corticosteroid therapy and cyclophosphamide, with clinical improvement. This case highlights the need for greater awareness of this relatively rare adverse effect of propylthiouracil.

Silicose / Silicosis

Os autores apresentam uma revisão da literatura nacional e internacional e discutem aspectos epidemiológicos, fisiopatológicos, funcionais e do diagnóstico da silicose. São revistas a classificação clínica, as formas de tratamento e outras doenças sílico relacionadas, como a tuberculose, o câncer de pulmão e a esclerodermia. Aspectos preventivos e médico-legais também são discutidos.

This chapter presents a review of the national and international literature on the subject of silicosis. Epidemiological, pathological, diagnostic and pulmonary function aspects are discussed. The clinical classification and methods of treating silicosis are reviewed, as are other silicarelated diseases such as tuberculosis, lung cancer and scleroderma. Prevention and medical-legal aspects are also discussed.

Autoantibodies in thalassaemia major: relationship with oral iron chelator L1.

Ninety patients with thalassaemia major were investigated for the occurrence of antinuclear antibodies (ANA), and those with ANA were tested for antibodies to histones (AHA). ANA were detected in 7 of 27 thalassemics on oral iron chelator L1, and in 2 of 63 thalassaemics not on L1 (p < 0.01). AHA were seen in 4 of 7 thalassemics receiving L1 with positive ANA, and in none of the 2 not receiving L1 (p < 0.03). Joint pains were seen in patients receiving L1, but in none of the patients not receiving L1. There was no correlation between hepatitis B or HIV positivity and presence of ANA or joint pains. While some amount of background ANA-positivity was found in patients with thalassaemia major, it was significantly more in patients receiving L1. Laboratory evidence of drug-induced lupus-like reaction was seen only in patients who received L1. In view of serious concerns about the safety of L1 and wide variations in the incidence and severity of adverse reactions reported by different sources, an urgent regulatory audit of all trial centres is essential.

Auto-imunidade como imunodeficiência / Autoimmunity as immunodeficiency

As doenças auto-imunes näo podem mais ser atribuídas à simples presença de clones linfocitários auto-reativos, porque esses clones podem ser encontrados em indivíduos sadios como componentes de redes idiotípicas normais. Por outro lado, sídromes similares ao lúpus eritematoso sistêmico (LES) podem ser induzidas em camundongos normais pela injeçäo de um idiotipo anti-DNA freqüentemente encontrado em pacientes de LES (16/6), que também é encontrado no soro normal. Em camundongos NZB/W, que desenvolvem espontaneamente uma síndrome lupóide, ocorrem taxas anormalmente elevadas da ativaçäo de um subtipo de linfócitos T (Th2), que podem ser responsáveis pela ativaçäo policlonal de linfócitos B, levando à produçäo de vários auto-anticorpos patogênicos. A encefalomielite alérgica experimental (EAE) pode ser induzida em camundongos pela injeçäo de clones de células T reativos com a proteína básica da mielina (MBP); pode também ser prevenida ou revertida, pela injeçäo de outros clones MBP-reativos. O processo fisiológico de ativaçäo de linfócitos T requer a apresentaçäo de peptídios ligados a produtos do MHC na membrana de linfócitos B ou de vários tipos de "células apresentadas". Há porém, exceçöes a essa regra. Interaçöes recíprocas diretas entre regiöes variáveis de receptores de linfócitos T e imunoglobulinas atuando como receptores em linfócitos B podem resultar na ativaçäo de ambas as células. Em doenças parasitárias crônicas, como a esquistossomose mansônica e a doença de Chagas, podem ocorrer idiotipos antiparasita capazes de ativar linfócitos T autólogos independentemente de processamento/apresentaçäo. Neste ensaio, sugerimos que o "pareamento independente" de linfócitos T e B, contornando a necessidade de processamento/apresentaçäo, pode ser importante na gênese de doenças auto-imunes e nas formas severas de parasitoses crônicas. A eficácia de injeçöes de imunoglobulinas normais poliespecíficas no tratamento de várias doenças auto-imunes também sugere que a restauraçäo da saúde resulta do restabelecimento de padröes normais de conectividade idiotípica