Resolution of dysglycaemia after treatment of monoclonal gammopathy of endocrine significance

In very rare cases of monoclonal gammopathy, insulin-binding paraprotein can cause disabling hypoglycaemia. We report a 67-year-old man re-evaluated for hyperinsulinaemic hypoglycaemia that persisted despite distal pancreatectomy. He had no medical history of diabetes mellitus or autoimmune disease but was being monitored for an IgG kappa monoclonal gammopathy of undetermined significance. On glucose tolerance testing, hyperglycaemia occurred at 60 minutes (glucose 216mg/dL), and hypoglycaemia at 300 minutes (52.2mg/dL) concurrent with an apparent plasma insulin concentration of 52,850pmol/L on immunoassay. Laboratory investigation revealed an IgG2 kappa with very high binding capacity but low affinity (Kd 1.43x10-6 mol/L) for insulin. The monoclonal gammopathy was restaged as smouldering myeloma not warranting plasma cell directed therapy from a haematological standpoint. Plasma exchange reduced paraprotein levels and improved fasting capillary glucose levels. Lenalidomide was used to treat disabling hypoglycaemia, successfully depleting paraprotein and leading to resolution of symptoms.