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هذه الصفحة مخصصة للاطباء فقط وهي صفحة تقديم حالات السكر المثيرة للاهتمام
diabetic case study
16 February 2009 03:37 pm
 459 views
for all physitians who are interested in joining this clinical activity by submitting a difficult or interesting case of type 1 or 2 diabetes mellitus please send a summary of the case and the name of the doctor and hospital name to the following e-mail (ali_hilly2000@yahoo.com)in order to puplish it through this site and for those who want to comment or share his or her opinion please send it to the same above e-mail or through the spesified field at the bottom of this page with my best regards
Dr.Ali Alhilly
diwaniya teaching hospital
diabetic clinic
diabetic case No.1 :(insulin resistance in type 1 DM case) by Dr.Ali Alhilly ,diwaniya teaching hospital ,diabetic clinic
Summary : 18 years old girl has type 1 DM since 10 years .she was on mixtard insulin twice daily 20 \15 IU.patient has no previous SMBG record . She presented with very high blood sugar readings for the last one month and despite meticulous efforts to stabilize her glycemia (psychological support ,frequent SMBG ,correction by additional insulin doses , restricted meal plan, monitoring of injection technique ,use of insulin with most recent manufacture date , cheching glucometer accuracy )she continued to have high surges of blood sugars (300-600 mg\dl). Examination : conscious ,not acidotic PR=120\min,BP=140\100mm.Hg temp 38.5 C , slight tenderness at the left renal area . Investigations : CBP + ESR normal ,GUE showed UTI , culture showed growth of E-Coli sensitive to amikacin and ciprofluxacin ,sugar +++,ketone bodies –ve,24 hours urinary albumin = 0.2gm \24 hours,GFR =110ml\day, lipid profile normal, LFT normal ,RFT normal,T3,T4,TSH ,S.cortisol were normal ,abdominal U\S showed left renal stone. CXR Normal ,ECG showed sinus tachycardia. HbA1c = 9.5 %. provisional diagnosis : uncontrolled diabetes due to chronic untreated UTI
Management :cefotaxime 2gm\day,soluble insulin 15 units 3 times daily + additional correction doses (5-20 IU),IVF ,Enalipril 5mg\day. After infection was stabilized and patient become afebrile patient was discharged and kept on ciprodar 500 bid ,30 IU mixtard .at the morning 15 IU sol. Before lunch and 15 IU mixtard. at evening .patient was instructed to do SMBG record at home . At follow up visit to the diabetic clinic patient brought her SMBG record which was full of very high figures (500-600mg\dl)despite meticulous checking by patient and very supportive family . Patient was re-admitted to hospital and was put on high dose insulin therapy 50 IU NPH +15 IU sol.at morning ,15 IU sol. every 4 hours,25 IU NPH +15 IU at evening .(total dose =175 IU\day). Despite this high dose regimen patient continued to have very high blood sugar readings (>600mg\dl) without experiencing hypoglycemias even after putting patient on total dose of >200 IU \day
Final diagnosis : immune- mediated insulin resistance .
Steroid therapy was initiated 30 mg \day and within 3 days patient responded dramatically and her glycemia started to normalize and patient had frequent hypoglycemias and finally put on less insulin doses with tapering of steroid .the dilemma now is that patient cant wheened off steroid because attempts to do that through 6 months was faced by agressive rise in blood glucose and patient started to have side effects of steroid including cushing syndrome.in addition to the frequent unpredictable hypers and hypos
so whats the answer for such case
comment No. 1 :by Sir Majeed Abdulameer
*These data indicates clearly a case of poorly controlled DM . The UTI is most likely secondary to her poor glycemic control rather than a cause for it. It is surprising that despite the very poor glycemic control , her urine ketone is still negative !!! The high 24 hours urinary protein is partly caused by the UTI and the renal stone PLUS possible associated early nephropathy as her BP is high 140/100 mm Hg with a PR of 120/min and the GFR is also high , this is expected in long standing poorly controlled diabetics. Additional useful information are missing : BMI ?, the menstrual cycle ? is there any clinical evidence of insulin resistance such as acanthosis nigricans or skin tags ? does she has hirsutism? was there a history of weight loss at this stage ?
*Enalapril is a very good choice for the high BP and possible nephropathy.Did she continue to be ketone free despite the very high blood glucose ?
*This is one of the possible differential diagnoses .Other causes that need consideration include other conditions associated with insulin resistance ( Acromegaly , Cushing and thyrotoxicosis ), an associated PCO should be excluded in young females . Coeliac disease , a frequent occurance in type 1 diabetes though being a very remote possibility in this case but still need to be considered. Measurement of insulin antibodies levels may be helpful but I think it is not available in Iraq
*Steroids would be useful in all cases of immune mediated deterioration of blood glucose control such as thyrotoxicosis and coeliac disease and is not necessarely diagnostic of " immune mediated insulin resistance " . Please repeat the thyroid function tests in a reliable lab and send me the above mentioned missing information .
Dr. Majeed
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