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LETTER TO THE EDITOR
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 168-169

Hyperinsulinemia with acute severe malnutrition


Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria

Date of Web Publication14-Oct-2016

Correspondence Address:
Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1118-8561.192396

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How to cite this article:
Aliyu I. Hyperinsulinemia with acute severe malnutrition. Sahel Med J 2016;19:168-9

How to cite this URL:
Aliyu I. Hyperinsulinemia with acute severe malnutrition. Sahel Med J [serial online] 2016 [cited 2022 Nov 30];19:168-9. Available from: https://www.smjonline.org/text.asp?2016/19/3/168/192396



Sir,

Protein–energy malnutrition (PEM) is prevalent in most developing countries [1],[2] and it accounts for 40.1% of childhood mortality in Enugu, Nigeria.[3] Though the exact mechanism of PEM is not completely understood; poverty, ignorance, and infection are associated risk factors.

Persistent hyperinsulinemic hypoglycemia is a heterogeneous disease that may presents in the neonatal period; though it can also occur in older age children, adolescents, and adults.[4] In developed countries, where healthcare is accessible diagnosis may be established early in life, however, in a setting where healthcare facilities are not easily accessible like in Nigeria, diagnosis may be delayed with the child presenting late with complications; notable among them are repeated seizures with neurologic deficits and death; but malnutrition as a primary presentation is uncommon. More so hypoglycemia is a common complication of severe acute malnutrition (SAM);[5] therefore a case of a 12-month-old girl who was malnourished with hyperinsulinemia and hypoglycemia is reported.

A 12-month-old girl presented with fever, cough, and difficulty in breathing associated with weight loss and peripheral edema; parents noticed the weight loss at about the sixth month of life. She was not exclusively breastfed; and was on cereal based diet. Though it was well tolerated, she progressively lost weight. The mid-arm circumference was 9 cm; weight was 7 kg which was <−3 Z-score for age, the length was 70 cm while the occipitofrontal circumference was 47 cm with pedal edema [Figure 1]. She was managed for pneumonia with acute severe malnutrition. The chest infection was controlled, but she had persistent hypoglycemia despite adequate feeding. This was mostly noticed at night when the frequency of feeding was less. An analysis of the urine revealed the absence of ketones and the blood insulin assay was elevated. Therefore, the diagnosis of hyperinsulinemia was made. The frequency of feeding was increased also at night and was treated with octreotide. Hypoglycemia was controlled, and the patient was referred to a tertiary center for further care.
Figure 1: Wasting with bilateral pedal edema

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Glucose is the main immediate source of energy; it is produced through the breakdown of glycogen, gluconeogenesis, and fatty acid metabolism. In persistent hyperinsulinemic hypoglycemia of infancy, there is a defect in glucose regulation of insulin secretion resulting in excessive insulin secretion. The insulin receptor has 2 components; the sulfonylurea receptor 1 and the potassium channel. Deficiency of adequate calories coupled with poor weaning practice contributed to the overt malnutrition in the index case. Hypoglycemia is a common complication in severe malnutrition therefore other possible causes could easily be overlooked. More so increased insulin secretion has also been implicated in the pathogenesis of kwashiorkor; hence it could be a diagnostic dilemma if other possible differentials are not entertained, persistence of hypoglycemia despite adequate feeding made SAM as the sole cause unlikely. Therefore, the decision to treat for hyperinsulinemia resulted in control of hypoglycemia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Abidoye RO, Sikabofori. A study of prevalence of protein energy malnutrition among 0-5 years in rural Benue State, Nigeria. Nutr Health 2000;13:235-47.  Back to cited text no. 1
[PUBMED]    
2.
Hamidu JL, Salami HA, Ekanem AU, Hamman L. Prevalence of protein–energy malnutrition in Maiduguri. Nigeria Afr J Biomed 2003;6:123-7.  Back to cited text no. 2
    
3.
Ubesie AC, Ibeziako NS, Ndiokwelu CI, Uzoka CM, Nwafor CA. Under-five protein energy malnutrition admitted at the University of Nigeria Teaching Hospital, Enugu: A 10 year retrospective review. Nutr J 2012;11:43.  Back to cited text no. 3
[PUBMED]    
4.
Nhampossa T, Sigaúque B, Machevo S, Macete E, Alonso P, Bassat Q, et al. Severe malnutrition among children under the age of 5 years admitted to a rural district hospital in southern Mozambique. Public Health Nutr 2013;16:1565-74.  Back to cited text no. 4
    
5.
Christesen HB, Brusgaard K, Beck Nielsen H, Brock Jacobsen B. Non-insulinoma persistent hyperinsulinaemic hypoglycaemia caused by an activating glucokinase mutation: Hypoglycaemia unawareness and attacks. Clin Endocrinol (Oxf) 2008;68:747-55.  Back to cited text no. 5
[PUBMED]    


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