Chronicle of Diabetes Research and Practice

: 2023  |  Volume : 2  |  Issue : 3  |  Page : 30--32

Case Studies


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. Case Studies.Chron Diabetes Res Pract 2023;2:30-32

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. Case Studies. Chron Diabetes Res Pract [serial online] 2023 [cited 2023 Mar 30 ];2:30-32
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 1. Hypoglycemic Encephalopathy Caused by Insulinoma: A Case Report

Akshay R. Kothari, Kiran S. Shah, Lotika S. Purohit, Amit A. Giram*

*Grant Medical College and Sir J.J Group of Hospitals, Mumbai, Maharashtra, India

E-mail: [email protected]

Hypoglycemic encephalopathy is a critical condition associated with a poor prognosis. Tumor-induced hypoglycemia is a rare clinical condition of hypoglycemia that occurs when a pancreatic islet beta-cell tumor insulinoma produces excessive insulin. We present the case of a non-diabetic 62-year-old woman with a 15-year history of recurrent fasting hypoglycemia, whose symptoms of weakness and giddiness would develop in the early mornings, prompting her to request sweetened tea and glucose cookies, after which her symptoms would improve. Investigations showed raised levels of insulin, C-peptide, pro-insulin, as well as a decreased value of betahydroxybutyrate and a negative screen for urine sulfonylureas. Computed tomography abdomen revealed a focal lesion in the body of the pancreas suggestive of insulinoma. Based on these investigations, a diagnosis of endogenous hyperinsulinism was made. This case emphasizes the importance of thorough history taking, attention, and observation in making a new diagnosis that has the potential to alter a patient's health care and alleviate clinical outcomes, where the patient ignored the symptoms for nearly 15 years, leading to the development of hypoglycemic encephalopathy.

 2. Challenges in Classifying DM: A Rare Case of Lipodystrophic DM

Aishwarya Singh*, Rohini Rokkam, Amritava Ghosh

*All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

E-mail: [email protected]

Introduction: Lipodystrophy syndromes are a group of inherited or acquired disorders with a striking feature of either a partial or complete lack of adiposity associated with metabolic and other manifestations. The metabolic abnormalities associated with lipodystrophy include insulin resistance, often leading to diabetes mellitus, hypertriglyceridemia that may lead to acute pancreatitis, and hepatic steatosis, causing cirrhosis later. The most common subtype, i.e., Dunnigan-type or Familial Partial Lipodystrophy 2 (OMIM 151660), is caused by autosomal dominant pathogenic rare variants in the LMNA gene encoding lamin A/C. Management of lipodystrophies focuses on preventing and treating metabolic complications.

Case Report: This was an 18-year-old female, nonobese, with young onset ketosis-prone Diabetes mellitus with severe hypertriglyceridemia with fatty liver and polycystic ovary syndrome presenting with a history of recurrent admissions for diabetic ketoacidosis and acute pancreatitis. The attacks were precipitated by poor compliance with drugs because of financial issues. Her serum during this episode was lipemic with a serum triglyceride of over 5000 mg/dL. She responded to pain management and insulin infusion and was discharged on pancreatic lipase, fenofibrate, atorvastatin, Omega 3 fatty acids, metformin, and insulin.

Discussion: Due to increased lipid synthesis and very-low-density lipoprotein production as well as reduced lipoprotein lipase mediated clearance of triglycerides-rich lipoproteins, there is a loss of subcutaneous fat in extremities and buttocks, with increased visceral fat. Deficient adipose mass in lipodystrophy results in typical metabolic complications, including insulin resistance and diabetes, hypertriglyceridemia, polycystic ovary syndrome, and nonalcoholic fatty liver disease. Familial partial lipodystrophy in women may present with polycystic ovary syndrome with resulting masculinization and menstrual irregularities. Other types include congenital generalized lipodystrophy (near total absence of body fat starting at birth or shortly after, generalized muscularity, and metabolic abnormalities), progeria associated lipodystrophy, and acquired partial lipodystrophy (loss of subcutaneous fat).

 3. A Case of Adrenal Cortical Carcinoma Presenting as Liver Dysfunction and Uncontrolled Diabetes

Patil Rohit Subhash*, S. R. Rangabashyam, C. Arul Murugan, R. Prabu

*Vinayaka Missions Kirupananda Variyar Medical College and Hospitals, Salem, Tamil Nadu, India

E-mail: [email protected]

Introduction: The majority of adrenal cortical carcinomas are hormone-secreting and can manifest as Cushing's syndrome. It is important to be cognizant of evaluating secondary causes of diabetes mellitus in uncontrolled diabetics through detailed history-taking and physical examination.

Case Report: A 57-year-old woman with past medical history of uncontrolled type 2 diabetes mellitus (DM2) initially presented to the hospital with altered mental status and was admitted for UTI. Mental status resolved with antibiotics. However, elevated liver enzymes at presentation prompted a RUQ ultrasound which revealed an 8 cm mass concerning for an adrenal etiology. Endocrinology was consulted for further management. At initial encounter, the patient reported generalized fatigue and weakness but denied any changes in weight or distribution of fat, striae, easy bruising, hirsutism, headache, palpitations, and flushing. Menopause was 1 year ago. DM2 was diagnosed at least 9 years prior and treated with two oral agents and insulin aspart 70-30 mix 20 units BID with HbA1c of 12.3%. Vitals were normal and physical exam was significant for mild hirsutism and buffalo hump and 2+ edema in the bilateral lower extremities.

Discussion: Even hormone-secreting ACCS can be asymptomatic. Although uncontrolled DM2 can be due to multiple factors, taking the extra time to conduct a thorough history and physical exam on patients with sudden or progressively worsening glycemic control for symptoms and signs of Cushing's syndrome is extremely beneficial.

 4. Mucor in the Era of COVID HAVOC Complicating Diabetes

Santa Subhra Chatterjee*, Ajitesh Roy

*Vivekananda Institute of Medical Science, Kolkata, West Bengal, India

E-mail: [email protected]

Introduction: Mucorales are ubiquitous found on decaying vegetation and soil. Rhizopus, Mucor, and Rhizomucor constitutes. Hyphae attacks vasculature and cause infarction and necrosis of host tissues. Mucor gains access via spore inhalation usually. Risk factors include diabetes, steroid use, and transplanted candidates. Recently, COVID-19 pandemic led to rise in the incidence of mucormycosis which we have presented here.

We aimed to assess the cause of nasal and ocular symptoms in context of post covid scenario.

Case Report: A 60-year-old diabetic male patient with recent history of COVID-19 attended our OPD with nasal onstruction and left proptosis. He was having poor glycemic status and was on subcutaneous basal bolus insulin regimen post-COVID as he also needed steroids for hypoxic respiratory failure. He was having some throbbing pain over left cheek and mild blurring of vision in the left eye with occasional double vision on medial and upgaze. Examination showed proptosis of the left eye and broadening of the nose.

Computed tomography PNS showed soft-tissue-enhancing mass in left sphenoid, maxillary sinus, pterygomaxillary fissure, medial and inferior rectus at extracoronal plane of left orbit. Roof of maxillary sinus was destroyed by the mass. Magnetic resonance imaging orbit revealed hyperintense signals in the medial and inferior walls of the orbit. A nasal biopsy showed plenty of aseptate fungal hyphae resembling mucor species.

Discussion: Rhinocerebral mucormycosis is the most common form seen. Initially presents as sinusitis but as disease progresses perinasal facial edema, palate necrosis, orbital edema, proptosis and ophthalmoplegia ensues. Diagnosis relies on histopathology but tissues should not be crushed and polymerase chain reaction may help in species identification. Combined medical and aggressive surgery may result in cure.

 5. A Case of Diabetic Leukocytosis

Sunil Narayan Kamble

K.J. Somaiya Super Speciality Hospital, Sion, Mumbai, Maharashtra, India

E-mail: [email protected]

Case Report: A 49-year-old female for 1st consultation k/c/o DM since 5 years c/o weakness. No fever/cough/burning micturition/joint pain in last 3 months 1st visit –T – 95.8F, Pulse -82/min, spo2 – 97%. Blood pressure (BP) -142/86 mm of Hg. BS- F-148mg/dl, PP – 216 mg/dl, serum creatinine -049, complete blood count (CBC) – Hb-11 , TLC 13500, N68L21M5E6B0 PLT COUNT – 3 Lakhs , Urine R N M- Sugar 2+, rest n OHA changed , AS TLC high broad spectrum ANTIBIOTIC for 5 days asked for fu after 10 days.

After 10 FU – No complaint. T -96F, Pulse - 82/min, Spo2 - 99%, BP - 112/80mm of Hg, BS F- 126 mg/dl, PP- 189 mg/dl, CBC – Hb -11.1, TLC -14000, N69L20M5E5B0, PLT count 2.66 Lakhs, ESR 24. Continue with same oha, no antibiotic given. Advise follow-up after 1 month.

After 1 month - No complaint. CBC – Hb-11 TLC -14900 N65L28E1M4B2. PLT count – 2.25 lakhs.

Blood culture, chest X-ray both are normal Referred to Haematologist i/v/o INCRASED TLC.

Haematologist asked for (1) FISH for BCR, ABL. (2) CBC. (3) Peripheral smear. (4) C-reactive protein (CRP) Quantitative and started with Tab. Amoxycillin + clavulinic acid (625) twice a day for 5 days.

After 5 days 1. CBC – Hb-12.2, TLC 14.17, N63.7, L24.6, E4.9, M6, B0.8, PLT COUNT-2.10. CRP- 2.76, PS – Normal FISH TEST – Normal. USG Abd n P - Mild hepatomegaly with Grade 1 fatty liver, CA 125 – Normal serum procalcitonin - normal bone marrow aspiration and biopsy – Normal.

Discussion: As all possible causes for raised TLC worked out but everything is normal. The possible diagnosis: (1) Diabetic leukocytosis and (2) idiopathic Leukocytosis. (1) In several studies association of white blood cell (WBC) as a marker of subclinical inflammation with insulin resistance and type 2 diabetes has been reported. (2) Elevated WBC even within normal rage is associated with chronic complications in type 2.

 6. Hirata's Disease – A Rare Cause of Hypoglycemia in A 65 Tear Old Woman

Kalpesh Joshi*, Dhruvi Joshi

*Lotus Hospital, Valsad, Gujarat, India

E-mail: [email protected]

Introduction: Insulin autoimmune syndrome (IAS), also called Hirata's disease, is a rare condition characterized by hypoglycemic episodes due to presence of high titres of insulin autoantibodies (IAA) in serum. Being third leading cause of hypoglycemia in Japanese people, it is rare in people of other ethnicities.

Case Report: A 65-year-old female, k/c/o hypothyroidism and psoriasis, came with history of recurrent hypoglycemic episodes. No history of diabetes, hypertension or consumption of any modern medicines in the last 2 years. She started developing recurrent episodes of giddiness, perspiration, and weakness since a month. All routine investigations including computed tomography and magnetic resonance imaging were normal. Hypoglycemic episodes noticed during the period were treated with IV glucose, but other symptoms remained persistent. After being admitted for investigation, capillary blood glucose was monitored 1 hourly and blood sample was collected for blood glucose, serum insulin, c-peptide, electrolytes and acetone.

Plasma blood glucose - 52 mg% serum acetone: 2 MG/dl serum insulin: >1000 μU/ml S. C- peptide: 14.66 ng/ml serum sodium: 136 meq/l serum potassium: 4.5 meq/l serum chloride: 95 meq/l.

Patient had never taken insulin in past. Insulinoma or IAS was suspected. As, in insulinoma, serum insulin titer is not this high, sample for IAA was sent. IAA were positive and >100.

Discussion: Hence, diagnosis of IAS was made. The patient was started on predisolone, 20mg daily. No further hypoglycemic episodes were documented. The presence of IAA can mimic many pathological conditions, prompting expensive/harmful diagnostic tests, even pancreactomy (for insulinoma), stressing importance of testing IAA in non-diabetic adults with hyperinsulinemic hypoglycemia.

 7. Insulin Gene Mutation Presenting as Diabetes in a 2-Year-Old Child

Rejitha Jagesh*, Mathew John, M. J. Manju

*Providence Endocrine and Diabetes Specialty Centre, Thiruvananthapuram, Kerala, India

E-mail: [email protected]

A 2.8-year-old single female child of a non-consanguineous parent reported to our clinic in 2018 with severe hyperglycemia (FPG: 214 mg/dl, PPG: 573 mg/dl, HbA1c:14.6%, Urine acetone: negative). Clinical examination revealed severe vaginitis, angular cheilitis, and dehydration. Height: 83.3 cm (C) that results in the amino acid substitution of Glycine for Cysteine at codon 43 (p. Cys43Gly; ENST00000397262.5) was detected. The variant was classified as likely pathogenic. Although most dominant mutations of the insulin (INS) gene present as permanent neonatal diabetes (PNT), 9 % presented between 1 to 10 years of age. Similar variants described in the literature presented permanent neonatal diabetes. Summary: We have described a mutation of the INS gene in a child presenting with diabetes at two years of age, who is C-peptide negative and GAD autoantibody negative.

 8. An Innovative Therapy for Diabetic Foot Ulcer with Hyperglycemic Excursions

Abhijit Pundkar*, Abhijit Chavan, Jitendra Ingole

*Smt. Kashibai Navale Medical College and Hospital, Pune, Maharashtra, India

E-mail: [email protected]

Introduction: Diabetic foot ulcer is the result of poor glycemic control, underlying neuropathy, peripheral vascular disease, poor foot care, and associated with osteomyelitis and amputation of foot. Different dressing modalities used in diabetic foot ulcers are hydrocolloids, hydrogels, foams, silver impregnated dressings, Vinegar-soaked dressings, and honey dressing. Honey has been used as a wound dressing for thousands of years, but only in more recent times has a scientific explanation become available for its effectiveness. It is now realized that honey is a biologic wound dressing with multiple bioactivities that work in concert to expedite the healing process.

Case Report: A 52-years-old male k/c/o – type 2 diabetes mellitus with nonhealing diabetic foot ulcer of the left lower limb with uncontrolled BSL despite injection regular insulin and glargine managed with continuous glucose monitoring (CGM) which can improve glycemic control and wound healing with the help of honey dressing in 22 days. CGM used in nonhealing diabetic foot ulcer which enables real-time glucose display, trend information, and alarms, can improve glycemic control and wound healing in diabetic patient.

Discussion: Honey is a biologic wound dressing with multiple bioactivities that work in concert to expedite the healing process. The physical properties of honey also expedite the healing process: its acidity increases the release of oxygen from hemoglobin, thereby making the wound environment less favorable for the activity of destructive proteases, and the high osmolarity of honey draws fluid out of the wound bed to create an outflow of lymph as occurs with negative pressure wound therapy. Honey also has a broad-spectrum antibacterial activity. Case shows honey dressing along with CGM proved an effective way in managing diabetic foot ulcer.

 9. Nonketotic Hyperglycemic Hemichorea, Hemiballismus: A Case Report

Shriya Gadve*, Tomesh Bisen, Ashok Bhupali

*Apple Saraswati Hospital, Kolhapur, Maharashtra, India

E-mail: [email protected]

Introduction: Nonketotic hyperglycemia is an unusual and rare cause of hemichorea hemiballismus.

Case Report: We present the case of a 60-year-old male known diabetic with poor glycemic control, who presented with involuntary movements-left hemichorea hemiballismus. His random blood glucose level was 350mg/dl. MRI brain showed hyperintense signal in right basal ganglia typically suggestive of nonketotic hyperglycemic hemichorea. Restoration of euglycemia along with treatment with haloperidol, tetrabenazine, and trihexyphenidyl led to eventual resolution of all symptoms.

Discussion: This case showed that glycemic control helps in the resolution of hemichorea, hemiballismus. Nonketotic hyperglycemia should be kept as differential diagnosis in patients with hemichorea.