Letter to the Editor
Autoimmune hypoglycemia syndrome associated with α lipoic acid consumption
Síndrome de hipoglucemia autoinmune asociado al consumo de ácido α lipoico
Theodora Michalopoulou Alevras
, Mireia Guerrero Gual, Carles Villabona Artero, Manuel Pérez-Maraver
Corresponding author
Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
Read
122
Timeswas read the article
44
Total PDF
78
Total HTML
Share statistics
array:24 [ "pii" => "S2387020615000339" "issn" => "23870206" "doi" => "10.1016/j.medcle.2014.02.004" "estado" => "S300" "fechaPublicacion" => "2015-01-20" "aid" => "2917" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2014" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2015;144:93-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 122 "formatos" => array:2 [ "HTML" => 78 "PDF" => 44 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775314001705" "issn" => "00257753" "doi" => "10.1016/j.medcli.2014.02.013" "estado" => "S300" "fechaPublicacion" => "2015-01-20" "aid" => "2917" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2015;144:93-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 265 "formatos" => array:2 [ "HTML" => 234 "PDF" => 31 ] ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Síndrome de hipoglucemia autoinmune asociado al consumo de ácido α lipoico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "93" "paginaFinal" => "94" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Autoimmune hypoglycemia syndrome associated with α lipoic acid consumption" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Theodora Michalopoulou Alevras, Mireia Guerrero Gual, Carles Villabona Artero, Manuel Pérez-Maraver" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Theodora" "apellidos" => "Michalopoulou Alevras" ] 1 => array:2 [ "nombre" => "Mireia" "apellidos" => "Guerrero Gual" ] 2 => array:2 [ "nombre" => "Carles" "apellidos" => "Villabona Artero" ] 3 => array:2 [ "nombre" => "Manuel" "apellidos" => "Pérez-Maraver" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020615000339" "doi" => "10.1016/j.medcle.2014.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000339?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775314001705?idApp=UINPBA00004N" "url" => "/00257753/0000014400000002/v2_201506091725/S0025775314001705/v2_201506091725/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020615000388" "issn" => "23870206" "doi" => "10.1016/j.medcle.2014.03.002" "estado" => "S300" "fechaPublicacion" => "2015-01-20" "aid" => "2936" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2015;144:94-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 107 "formatos" => array:2 [ "HTML" => 51 "PDF" => 56 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Platypnea-orthodeoxia syndrome and Budd–Chiari syndrome: An unreported association" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "94" "paginaFinal" => "95" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de platipnea-ortodeoxia y síndrome de Budd-Chiari: una asociación inédita" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pablo Demelo-Rodríguez, Jorge del Toro-Cervera" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Pablo" "apellidos" => "Demelo-Rodríguez" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "del Toro-Cervera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775314002255" "doi" => "10.1016/j.medcli.2014.03.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775314002255?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000388?idApp=UINPBA00004N" "url" => "/23870206/0000014400000002/v1_201509250127/S2387020615000388/v1_201509250127/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020615000315" "issn" => "23870206" "doi" => "10.1016/j.medcle.2014.02.003" "estado" => "S300" "fechaPublicacion" => "2015-01-20" "aid" => "2916" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2015;144:92-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 90 "formatos" => array:2 [ "HTML" => 64 "PDF" => 26 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Dementia solved with surgery: Report of a case" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "92" "paginaFinal" => "93" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Demencia curada con cirugía: a propósito de un caso" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cristina Tejera Pérez, José Ángel Flores García" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Cristina" "apellidos" => "Tejera Pérez" ] 1 => array:2 [ "nombre" => "José Ángel" "apellidos" => "Flores García" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775314001699" "doi" => "10.1016/j.medcli.2014.02.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775314001699?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000315?idApp=UINPBA00004N" "url" => "/23870206/0000014400000002/v1_201509250127/S2387020615000315/v1_201509250127/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Autoimmune hypoglycemia syndrome associated with <span class="elsevierStyleBold">α</span> lipoic acid consumption" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "93" "paginaFinal" => "94" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Theodora Michalopoulou Alevras, Mireia Guerrero Gual, Carles Villabona Artero, Manuel Pérez-Maraver" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Theodora" "apellidos" => "Michalopoulou Alevras" "email" => array:1 [ 0 => "michalopoulou@bellvitgehospital.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Mireia" "apellidos" => "Guerrero Gual" ] 2 => array:2 [ "nombre" => "Carles" "apellidos" => "Villabona Artero" ] 3 => array:2 [ "nombre" => "Manuel" "apellidos" => "Pérez-Maraver" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de hipoglucemia autoinmune asociado al consumo de ácido <span class="elsevierStyleBold">α</span> lipoico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The insulin autoimmune syndrome (IAS) is a rare cause of endogenous hyperinsulinism, characterised by fasting hypoglycaemia, postprandial hypoglycaemia or both, by very high levels of insulin and by positive anti-insulin autoantibodies (IAA).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It can be induced by certain drugs, especially those with sulfhydryl groups, which have been related to up to 50% of the cases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In particular, its onset can be triggered by the α lipoic acid (ALA), increasingly used during the last years as nutritional supplement.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The case of a Caucasian 55 year-old female referred for hypoglycaemia examination is presented. Allergy to iodinated contrast was the only relevant history; no use of habitual medication was reported. She had a 2-month case history characterised by adrenergic and neuroglycopenic symptoms, both in fasting and postprandial states, that resolved after food intake, and a 2<span class="elsevierStyleHsp" style=""></span>kg weight gain (weight 53<span class="elsevierStyleHsp" style=""></span>kg, body mass index [BMI] 21<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>). The physical examination using devices was anodyne. The general laboratory tests showed blood sugar levels of 3.2<span class="elsevierStyleHsp" style=""></span>mmol/L (4.1–6.9) and haemoglobin (HbA)<span class="elsevierStyleInf">1c</span> of 5.6%. A fasting test was performed and it was positive at 3<span class="elsevierStyleHsp" style=""></span>h with blood sugar levels of 2.4<span class="elsevierStyleHsp" style=""></span>mmol/L (4.1–6.9); insulinemia: 1.033<span class="elsevierStyleHsp" style=""></span>pmol/L (21–174); C peptide: 4.10<span class="elsevierStyleHsp" style=""></span>nmol/L (0.26–1.44); and cortisol 419<span class="elsevierStyleHsp" style=""></span>nmol/L (155–678). The determination of urine sulfonylurea was negative. IAA determination was done.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A treatment with fractionated diet and 200<span class="elsevierStyleHsp" style=""></span>g of iv glucose was established, with recurrence of hypoglycaemia and occasional postprandial hyperglycaemia episodes.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Complementary examinations were required to rule out insulinoma as the most frequent cause of endogenous hyperinsulinism. Given her history, 3 bolus of 50<span class="elsevierStyleHsp" style=""></span>mg/day of prednisone i.v. were administered prior to the computed tomography with contrast, which was normal. The echoendoscopy described a 3<span class="elsevierStyleHsp" style=""></span>mm nodule in the pancreatic head, whose citological analysis (fine-needle aspiration [FNA]) was consistent with normal pancreas. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results of the selective angiography with calcium stimulation. Finally, a diagnostic laparotomy was performed. Manual examination and intraoperative ultrasound scan of the pancreas were normal; thus, only an extended biopsy was performed. After the intervention, the blood sugar levels were normalised and gave place to the progressive withdrawal of i.v. glucose contribution. The received results of the IAAs (RIA) were 85.8% (normal: <8.20%). In a new targeted history, ALA intake (200<span class="elsevierStyleHsp" style=""></span>mg/day) as nutritional supplement (to prevent hair loss) during 15 days was discovered. The histological result showed hyperplasia of the pancreatic islets affecting approximately 10% of them and with insulin predominant expression. At the moment of discharge, the patient did not show new episodes of hypoglycaemia and insulinema was normalised. After one year, the IAA levels have decreased without reaching normalisation. Corticosteroids as preparation for the radiological techniques were the only immunomodulator treatment administered.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The IAS, first described by Hirata in 1970, is a rare cause of hypoglycaemia, except in Japan where it constitutes the third cause.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> The cases described in Caucasian population are scarce.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> It affects patients aged between 40 and 80 years old, with no difference in gender.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> It is associated to autoimmune diseases<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> (related to HLA-DRB1*0406 and HLA-DRB1*0403<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a>) such as systemic lupus erithematosus (SLE), among others<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>, and to the use of drugs with sulfhydryl groups<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> (e.g., methimazole). The physiopathology is barely known; the hypothesis is that the activity reducing the sulfhydryl group causes the rupture of the insulin disulphide bridges, exposing it to the cells that carry the antigen.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Hypoglycaemia is the consequence of the dissociation of insulin and the IAAs, which occurs asynchronously with blood sugar levels.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Insulinemia is higher than expected for an insulinoma, generally over 1000<span class="elsevierStyleHsp" style=""></span>pmol/L.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Little data has been reported about the histology of these cases, and they are about cells hyperplasia β.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> In 80% of the cases, the symptoms are resolved in weeks.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The treatment includes a diet fractionated in carbohydrates as first line, discontinuation of any medication associated to IAS and glucocorticoids (prednisone 30–60<span class="elsevierStyleHsp" style=""></span>mg/day).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Plasmapheresis and other treatments have demonstrated different results.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The ALA is an antioxidant with sulfhydryl groups. In 2004, it was approved as nutritional supplement and it is widely used nowadays.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Seventeen cases of IAS related to the ALA have been described in Japan, and recently 7 cases were reported in the Caucasian population.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> IAS was our definitive diagnosis considering the presence of hypoglycaemia with occasional episodes of postprandial hyperglycaemia, very high levels of insulinemia and positive IAAs, selective arteriography with increased levels of insulin in the entire gland without a gradient, histology with hyperplasia of the pancreatic islets and symptoms resolution after the administration of corticosteroids, in the context of previous administration of ALA. The application of the modified Karch and Lasagna causality algorithm<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> allowed the categorisation of our case as possible IAS related to the administration of ALA.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is the first case of IAS associated to the use of ALA in Spain. The use of ALA must be included in the habitual history of patients under examination for endogenous hyperinsulinism.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Michalopoulou Alevras T, Guerrero Gual M, Villabona Artero C, Pérez-Maraver M. Síndrome de hipoglucemia autoinmune asociado al consumo de ácido α lipoico. Med Clin (Barc). 2015;144:93–94.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Reference values, insulin: 21–174.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Arteries \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">30<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">60<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">90<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">120<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Insulin (pmol/L)</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Common hepatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">936 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1058 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1080 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1041 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gastroduodenal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1035 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1041 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">976 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1040 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Proximal splenic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1092 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1168 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1081 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1059 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1065 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Superior mesenteric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1042 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1046 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1042 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1066 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab901805.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Serum insulin concentration during the selective intra-arterial stimulation with calcium.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin autoimmune syndrome (IAS, Hirata disease)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y. Uchigata" 1 => "Y. Hirata" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Molecular mechanisms of endocrine and organ specific autoimmunity" "paginaInicial" => "133" "edicion" => "1st ed." "serieFecha" => "1999" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Drug induced insulin autoimmune syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Y. Uchigata" 1 => "Y. Hirata" 2 => "Y. Iwamoto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Diabetes Res Clin Pract" "fecha" => "2009" "volumen" => "83" "paginaInicial" => "19" "paginaFinal" => "20" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin autoimmunity in a case with spontaneous hypoglycemia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Hirata" 1 => "H. Ishizu" 2 => "N. Ouchi" 3 => "S. Motumura" 4 => "M. Abe" 5 => "Y. Hara" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Jpn Diabetes Soc" "fecha" => "1970" "volumen" => "13" "paginaInicial" => "312" "paginaFinal" => "320" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin autoinmune syndrome (IAS, Hirata disease)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y. Uchigata" 1 => "Y. Hirata" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ann Med Interne (Paris)" "fecha" => "1999" "volumen" => "150" "paginaInicial" => "245" "paginaFinal" => "253" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmune forms of hypoglycemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B.C. Lupsa" 1 => "A.Y. Chong" 2 => "E.K. Cochran" 3 => "M.A. Soos" 4 => "R.K. Semple" 5 => "P. Gorden" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2009" "volumen" => "88" "paginaInicial" => "141" "paginaFinal" => "153" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin autoimmune syndrome (Hirata disease) as differential diagnosis in patients with hyperinsulinemic hypoglycemia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.S. Paiva" 1 => "A.E. Pereira" 2 => "M.T. Lombardi" 3 => "S.K. Nishida" 4 => "T.T. Tachibana" 5 => "C. Ferrer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.mpa.0000220872.18153.72" "Revista" => array:6 [ "tituloSerie" => "Pancreas" "fecha" => "2006" "volumen" => "32" "paginaInicial" => "431" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16670629" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmune hypoglycemic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.B. Redmon" 1 => "F.Q. Nuttall" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Endocrinol Metab Clin North Am" "fecha" => "1999" "volumen" => "28" "paginaInicial" => "603" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10500933" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin autoimmune syndrome (Hirata disease) in European Caucasians taking α-lipoic acid" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Gullo" 1 => "J.L. Evans" 2 => "G. Sortino" 3 => "I.D. Goldfine" 4 => "R. Vigneri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/cen.12334" "Revista" => array:2 [ "tituloSerie" => "Clin Endocrinol (Oxf)" "fecha" => "2013" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Insulin autoimmune syndrome induced by α-lipoic acid in a Caucasian woman: case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Bresciani" 1 => "A. Bussi" 2 => "E. Bazzigaluppi" 3 => "G. Balestrieri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Diabetes Care" "fecha" => "2011" "volumen" => "34" "paginaInicial" => "146" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Causality classification at pharmacovigilance centres in the European community" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.H.B. Meyboom" 1 => "R.J. Royer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pharmacoepidemiol Drug Saf" "fecha" => "1992" "volumen" => "1" "paginaInicial" => "87" "paginaFinal" => "97" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014400000002/v1_201509250127/S2387020615000339/v1_201509250127/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014400000002/v1_201509250127/S2387020615000339/v1_201509250127/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000339?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 0 | 0 | 0 |
| 2017 October | 5 | 0 | 5 |
| 2017 September | 9 | 5 | 14 |
| 2017 August | 11 | 2 | 13 |
| 2017 July | 6 | 2 | 8 |
| 2017 June | 15 | 10 | 25 |
| 2017 May | 9 | 6 | 15 |
| 2017 April | 7 | 11 | 18 |
| 2017 March | 7 | 8 | 15 |
| 2017 February | 6 | 0 | 6 |
| 2017 January | 3 | 0 | 3 |
