Case Presentation
A 58-year-old manfrom Pakistan with a long-standing history of type 2 diabetes and diabetes-related complications and comorbidities presented to an endocrinologist. The patient reported that he has been on multidose insulin regimen for the last 20 years with insulin totaling over 250 units a day. Laboratory tests showed should the following review significant findings: (1) hemoglobin A1C level, >14%; (2) fasting glucose level, 398 mg/dL; and (3) creatinine level, 1.56 mg/dL. General physical examination revealed a middle-aged male patient with a body mass index of 23 kg/m2 and a large area of rubbery, hyperpigmented, necrotic masses below the umbilical line.
What is the diagnosis?
Fig.
Answer
Severe lipohypertrophy and necrosis of the lower abdomen, with likely minimal or no absorption of insulin in that area due to repeated use of similar area for insulin injections for the last 20+ years. Lipohypertrophy is a common complication at insulin injection sites, denoted by a “benign tumor-like swelling of fat tissue”.1 This can occur in both patients with type 1 and 2 diabetes mellitus who use subcutaneous insulin injections to control their blood glucose levels. Research has shown that patients with lipohypertrophy report an almost sixfold higher occurrence of unexplained hypoglycemia than those without.2 Poor glycemic control increases the risk of related organ diseases. Visual examination and palpation of the injection sites are strongly recommended to prevent this complication. Mr. A was educated on basic concepts of diabetes care, including correct insulin injection timing and technique. Importance of rotating the location of injection sites was stressed. He started the use of new insulin-naïve sites to improve absorption and prevent variability. New injection areas may lead to enhanced absorption and improved sensitivity; thus, the patient’s insulin dosage was reduced significantly. On subsequent 3-month follow-up visit, the patient’s body mass index was found to have improved to 27 kg/m2, and the hemoglobin A1C level was also found to be reduced to 8.3%. However, the appearance of the affected abdominal areas had not materially improved, and the patient will likely need a plastic surgery evaluation for the removal of the necrotic areas. This case demonstrates the importance of preventative education with initial prescribing of subcutaneous insulin and ongoing physical evaluation of insulin injection site. The use of smaller insulin needles and rotation of sites are critical factors in preventing hypertrophy, which leads to significant glucose variability, poor control, and an increased risk of diabetes-related complications.
Disclosure
The authors have no multiplicity of interest to disclose.
References
- 1.Mokta J.K., Mokta K.K., Panda P. Insulin lipodystrophy and lipohypertrophy. Indian J Endocrinol Metab. 2013;17(4):773–774. doi: 10.4103/2230-8210.113788. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Deng N., Zhang X., Zhao F., Wang Y., He H. Prevalence of lipohypertrophy in insulin-treated diabetes patients: a systematic review and meta-analysis. J Diabetes Investig. 2017;9(3):536–543. doi: 10.1111/jdi.12742. [DOI] [PMC free article] [PubMed] [Google Scholar]