We have studied a 2-year-old girl with acanthosis nigricans, glucose intolerance, marked hyperinsulinemia, and somatic features characteristic of the leprechaunism syndrome. Circulating plasma insulin levels were increased up to 50-fold and the patient showed a blunted hypoglycemic response to an injection of exogenous insulin (0.2 units/kg), indicating the presence of severe insulin resistance. Insulin purified from the patient's plasma was normal on the basis of chromatographic, electrophoretic, and immunologic criteria. Furthermore, the purified insulin competed effectively with 125I-labeled insulin for binding to insulin receptors on cultured IM-9 lymphocytes and rat fat cells and also exhibited normal biological potency when tested on rat fat cells. Anti-insulin receptor and anti-insulin antibodies were not detected in the patient's plasma, and plasma levels of glucagon, growth hormone, and cortisol were normal. Insulin binding to the patient's circulating mononuclear leukocytes was only slightly depressed into the low normal range and could not account for the severe insulin resistance. Studies on the patient's fibroblasts revealed normal levels of insulin receptors but a total absence of insulin's ability to accelerate glucose transport. Because rates of glucose transport and metabolism were normal in the basal state in the absence of insulin, we conclude that this patient's insulin resistance is due to an inherited cellular defect in the coupling mechanism between occupied insulin receptors and the plasma membrane glucose transport system. Leprechaunism is a rare, inherited disease characterized by an unusual facial appearance, hirsutism, cliteromegaly, and sparse subcutaneous fat stores (1-3). We have performed detailed metabolic studies on a 2-year-old girl with this syndrome who also presented with acanthosis nigricans and severe insulin resistance. Theoretically, insulin resistance can be due to abnormal beta cell secretory products, circulating insulin antagonists, or a cellular defect in insulin action (4). To elucidate the etiology of this patient's insulin resistance, each of these possibilities was examined in detail. Thus, we studied the integrity of her circulating insulin, assayed for potential insulin antagonists, measured cellular insulin receptors, and studied the insulin responsiveness of the patient's cultured fibroblasts in vitro. The results indicate that this patient's insulin resistance is due to a defect in insulin action distal to the insulin receptor.
CASE REPORTThe patient, an 18-month-old white girl, had been born after a full-term (41-week gestation) uncomplicated pregnancy and delivery to a gravida I para 1 28-year-old mother who had takenThe costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U. S. C. §1734 solely to indicate this fact. 3469 no medications during her pregnancy; birth weight was 2600 g. At birth she was noted to have bilateral ingui...