Immediate and late onset forms of insulin hypersensitivity presenting with glucose dysregulation

Abstract

We report the case of a 35-year-old woman allergic to detemir, neutral protamine Hagedorn, and glargine. Initially, local reactions to the insulin preparations occurred, which continued even after the types of insulin and the application areas were changed. When the use of insulin therapy was continued, the local reactions developed into systemic forms. Interestingly, blood glucose levels kept increasing to uncontrolled levels every time the cutaneous reactions occurred. The patient was referred to our clinic for further investigation. The results of the skin prick tests with insulin preparations were negative; however, the intradermal test results were positive with the following dilutions of the insulin preparations: 1/100 detemir, 1/100 glargine, 1/1.000 neutral protamine Hagedorn, and 1/1.000 regular insulin. The intradermal skin test results for glulisine, aspart, and lispro were negative. The levels of immunglobulin E specific to human insulin were high (194 kU/L; N 0-87 kU/L); whereas, the specific immunglobulin G4 levels were normal (35 mg/dL; N 0-125 mg/dL). We attempted to treat the patient with glulisine and aspart; however, similar reactions were observed with these insulin preparations as well. As we considered the levels of the anti-insulin antibodies and the late-onset local reactions, the insulin allergy in our patient was reckoned to be mediated by Type 1 and Type 4 hypersensitivity. The only insulin preparation that had never been used with this patient before was lispro, which also demonstrated negative intradermal skin test results. Therefore, we suggested the use of a continuous subcutaneous insulin infusion pump with lispro. Finally, the insulin hypersensitivity was successfully treated, and glycemic control was achieved.