Insulin-Derived Amyloidosis, The Insulin Ball, Amyloidoma: A Closer Look…

We recently reported a case of Insulin-Derived Amyloidosis, also known as The Insulin Ball and Amyloidoma.  We reported this in the Journal of the American Academy of Dermatology, reference 2020;6:351-3.  To read this article click HERE.  In my blog I am able to show more images than are allowed in the actual article…due to space considerations.  The importance of this article is that over 75 patients have been reported with subcutaneous insulin-induced amyloidosis, however, there has been only one other article reported in the dermatology literature.  This will result in a new addition to the causes of primary cutaneous amyloidosis–drug-induced amyloidosis, which will be added to every major dermatology textbook.  Our patient was unique in that he had 4 sites of subcutaneous amyloid, shown in these photographs…

 

 

All four of these subcutaneous masses were removed.  On histology the hemotoxylin and eosin (H & E) stains demonstrated amorphous eosinophilic staining material.

A congo red stain was significant for high congophilia.

When congo red stain is polorized, amyloid demonstrates an apple-green colored birefringence, as shown above this confirms the presence of amyloid.

The diagnosis of insulin-derived amyloidosis requires the demonstration of insulin in the biopsy material.  All four of the sites in our patient were positive on immunohistochemical staining.  The Nomenclature Committee of the International Society of Amyloidosis has designated this type of localized, iatrogenic, insulin-induced amyloid as AIns.  Other treatments, such as Enfuvirtide, which is used to treat patients with HIV infections, have also been shown to induce subcutaneous amyloid deposits and this has been designated as AEnf amyloid.  For more detailed information please refer to the open source article.  There will likely be more subcutaneously administered protein and peptide drugs to follow.  Stay tuned…