Localized cutaneous amyloid at an insulin injection site

Lonsdale-Eccles, A.A.; Gonda, Peter; Gilbertson, JA; Haworth, Andrea

doi:10.1111/j.1365-2230.2009.03711.x

Cited by 30 publications

(23 citation statements)

References 3 publications

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“…The first reports of this disorder included only patients under animal‐derived insulin treatment, giving place to the belief that the immunogenicity created was as a result of their animal origin. The newer analog, human insulin, which tends to generate fewer complications because of the generation of a scarce immunologic reaction, was later shown to also be causative of cases of nodular amyloidosis at the injection sites, ruling out the previous hypothesis …”

Section: Discussionmentioning

confidence: 99%

“…It has been suggested that the granulomas were the source of insulin‐degrading enzyme (IDE), which degraded the amyloidogenic precursors, resulting in amyloid deposition . Additional histopathologic findings described in some cases included the presence of calcium, as in the case 2, and areas of degenerated collagen and scar tissue . In most cases, the epidermis showed no changes or they were not specifically described, but the two cases with clinical appearance of acanthosis nigricans, showed acanthosis, ortho‐hyperkeratosis and increased pigmentation of the basal layer of the epidermis .…”

Section: Discussionmentioning

confidence: 99%

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Nodular amyloidosis at the sites of insulin injections

et al. 2015

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Amyloid is characterized by its fibrillary ultrastructure, and more than 20 proteins have been described to date as possible precursors. Among them, insulin and enfuvirtide represent the only medications described as amyloidogenic substances. We describe two diabetic patients, who were undergoing long-standing subcutaneous insulin treatment, who developed subcutaneous nodules at the sites of insulin injections. Histopathologic examination showed the presence of eosinophilic and amorphous masses in deep dermis, which stained positive with Congo red, amyloid P substance and anti-human insulin antibody. Whether the type of injected insulin played a role or not in the pathogenesis of the process is still uncertain, because all described patients used both fast-acting and slow-acting insulins at the same injection sites. Our second case showed nodular insulin-derived amyloid tumors only at the sites where exclusively fast-acting insulin was injected, which supports the notion that fast-acting insulin may also be the cause of this disorder. Insulin-derived nodular amyloidosis is probably underdiagnosed because of the small body of literature in comparison with the prevalence of insulin dependent diabetic patients. This underdiagnosis probably is because of its clinical similarity with the lesions of lipohypertrophy at the sites of insulin injections, which is rarely biopsied.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Nodular amyloidosis at the sites of insulin injections

et al. 2015

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“…11 Mass of firm tissue N ⁄ A + Swift et al 12 Firm, well-defined mass N ⁄ A + Albert et al 13 Two firm SC nodules None* + ? † Nagase 14 Two SC nodules N ⁄ A + Yumlu et al 4 SC tumour N ⁄ A + SC mass N ⁄ A + SC mass N ⁄ A + SC tumour N ⁄ A + Lonsdale-Eccles et al 15 Lump, clinically suggestive of a lipoma N ⁄ A ? ‡ + Shikama et al 10 SC mass N ⁄ A + Sie et al 16 Tumours N ⁄ A + Endo et al 9 Large, fixed, nontender, SC tumour Yellow-brown, epidermal atrophy + Present case Solid tumour with AN-like appearance Keratinized papillomatous brown plaque + ?…”

Section: Learning Pointsmentioning

confidence: 99%

Coexistence of insulin-derived amyloidosis and an overlying acanthosis nigricans-like lesion at the site of insulin injection

Kudo-Watanuki¹,

Kurihara²,

Yamamoto³

et al. 2012

Clinical and Experimental Dermatology

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A 59-year-old patient with diabetes mellitus had been treated with human recombinant insulin for 4 years. He developed a solid mass on his left abdomen at the insulin injection site, which had an overlying pigmented verrucous plaque and keratinized papules, similar to acanthosis nigricans (AN). On histological examination, the mass was found to contain a deposit of amyloid in the dermis, with hyperkeratosis, papillomatosis and acanthosis in the epidermis. Using immunohistochemistry, the amyloid deposits were found to be positive for insulin. A few cases of localized insulin-derived amyloid deposits at injection sites have been reported previously, but none had significant epidermal changes. The coexistence of dermal insulin-derived amyloidosis and an overlying AN-like change, as found in our patient, has not been reported previously, to our knowledge. The presence of a tumour-like lesion at the injection site should be carefully examined, as injection of insulin into amyloid deposits can result in insulin resistance.

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“…[ 5 ] In another case, within 14 days of changing the injection site, insulin dose decreased from 132 to 42 units/day, with improved glycemic control. [ 13 ]…”

Section: Introductionmentioning

confidence: 99%

Insulin-derived amyloidosis

Gupta

Singla

Singla³

2015

Indian J Endocr Metab

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Amyloidosis is the term for diseases caused by the extracellular deposition of insoluble polymeric protein fibrils in tissues and organs. Insulin-derived amyloidosis is a rare, yet significant complication of insulin therapy. Insulin-derived amyloidosis at injection site can cause poor glycemic control and increased insulin dose requirements because of the impairment in insulin absorption, which reverse on change of injection site and/or excision of the mass. This entity should be considered and assessed by histopathology and immunohistochemistry, in patients with firm/hard local site reactions, which do not regress after cessation of insulin injection at the affected site. Search strategy: PubMed was searched with terms “insulin amyloidosis”. Full text of articles available in English was reviewed. Relevant cross references were also reviewed. Last search was made on October 15, 2014.

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Localized cutaneous amyloid at an insulin injection site

Cited by 30 publications

References 3 publications

Nodular amyloidosis at the sites of insulin injections

Nodular amyloidosis at the sites of insulin injections

Coexistence of insulin-derived amyloidosis and an overlying acanthosis nigricans-like lesion at the site of insulin injection

Insulin-derived amyloidosis

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