Insulins
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Localised amyloidosis at injection sites: 4 case reports Three patients with type 1 diabetes mellitus (DM; patients 1, 3 and 4) and one patient (2) with type 2 DM developed localised amyloidosis, manifesting as amyloid tumours at their insulin injection sites [not all dosages stated]. In all patients, histological analysis of the tumours showed a strong immunoreaction with antibodies against human insulin, and tumour-like insulin-derived amyloid amyloidosis was diagnosed. In 2006, patient 1, a 33-year-old man, presented with a 5 × 2.5cm mobile subcutaneous tumour at his preferred insulin injection site on his left proximal forearm. He had received insulin [Insuman Rapid] since 1984, insulin aspart [NovoRapid] from 2004 to 2007, insulin suspension isophane [Insuman Basal] from 1988 to 2000, insulin glargine [Lantus] from 2000 to 2006, and insulin detemir [Levemir] since 2006; his average insulin dosage was 0.6 U/kg. The tumour was initially diagnosed as lipoma. The mass did not change in size during the subsequent 18 months, and was excised in July 2007. Patient 2, a 78-year-old woman whose history included renal insufficiency, diabetic nephropathy, thyroidectomy and hypertension, presented with a subcutaneous mass on her abdominal wall. She had been diagnosed with diabetes 4 years earlier, and had since been treated with insulin [Actrapid], insulin suspension isophane/insulin [Actrapan] and insulin suspension isophane [Protaphan] [duration of treatments to reaction onset not stated]. The tumour was excised in 2007. Patient 3, a 42-year-old woman with a 27-year history of DM, presented with a subcutaneous mass at her general insulin injection site on her abdomen. She had been receiving insulin [Combinsulin CR] from 1981 to 1982, insulin [Velasulin] from 1994 to 1996, insulin suspension isophane [Insulin Insulatard] from 1994 to 2001, insulin [Actrapid] from 1996 to 2006, insulin suspension isophane [Protaphan] from 2001 to 2006, and insulin aspart [NovoRapid] since 2006 [times to reaction onset not stated]. The mass was eventually resected. Patient 4, a 38-year-old man, developed a 5×5 cm tumour on his preferred insulin injection site on the flexor side of his left upper arm. His treatment had comprised insulin suspension isophane [Humaninsulin] and insulin lispro [Humalog] [duration of treatments to reaction onset not stated]. The mass was initially diagnosed as a lipoma. The tumour was resected in 2001. Author comment: "It is likely that insulin accumulates at the injection [sites]. This might be especially the case if these sites are used for repeated subcutaneous injections; the resorption of insulin may not proceed completely, leading to accumulation of insulin." Yumlu S, et al. Localized insulin-derived amyloidosis in patients with diabetes mellitus: a case report. Human Pathology 40: 1655-1660, No. 11, Nov 2009 801158214 Germany
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Reactions 9 Jan 2010 No. 1283
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