Insulin autoimmune syndrome (IAS), a rare cause of reversible autoimmune hypoglycemia also known as Hiratas disease, was first described by Hirata in Japan in 1970. Signs and symptoms
Affected patients are usually adults, experiencing multiple episodes of spontaneous hypoglycemia with neuroglycopenic symptoms. Causes
The cause of IAS is not clearly understood. However, interaction of disulfide bond in the insulin molecule with sulfhydryl group drugs such as methimazole, carbimazole, captopril, isoniazid, hydralazine, imipenem, and also with lipoic acid has been suggested. Drug-induced autoimmunization is evidenced by insulin autoantibodies appearing a few weeks after the intake of drug containing the sulfhydryl group. Additionally, IAS has a significant genetic predisposition as its association with specific HLA class has been observed. Pathophysiology
Following a meal, glucose concentration in the bloodstream rises, providing a stimulus for insulin secretion. Autoantibodies bind to these insulin molecules, rendering them unable to exert their effects. The resultant hyperglycemia promotes further insulin release. As glucose concentration eventually falls, insulin secretion also subsides, and the total insulin level decreases. Now insulin molecules spontaneously dissociate from the autoantibodies, giving rise to a raised free insulin level inappropriate for the glucose concentration, causing hypoglycemia. Diagnosis
Usual presenting features are multiple episodes of spontaneous hypoglycemia and appearance of insulin autoantibodies without prior history of administration of exogenous insulin. The insulin level is significantly high, usually up to 100 mIU/L, C-peptide level is markedly elevated, and insulin antibodies are positive. Treatment
The best known treatment is recommending frequent, small meals and to avoid simple sugars.
Erythema gyratum repens  is a figurate erythema that is rapidly moving and usually a marker of underlying cancer,: 143  usually from the lung. See also
Annular erythema of infancy
List of cutaneous conditions
List of cutaneous conditions associated with internal malignancy
List of migrating cutaneous conditions

References
Further reading
Prouty, Megan; Liu, Deede (2019). "Erythema Gyratum Repens Associated with Anal Cancer". New England Journal of Medicine. 380 (3): e3. doi:10.1056/NEJMicm1805833. ISSN 0028-4793. PMID 30650327. Illustration of the condition


== External links ==