1/13. Painful swelling of the thigh in a diabetic patient: diabetic muscle infarction.A 44-year-old woman with a 5-year history of poorly controlled Type 1 diabetes mellitus presented with a painful, firm and warm swelling in her right thigh. Pain was severe but the patient was not febrile, and had no history of trauma or abnormal exercise. Laboratory tests showed ketoacidosis, major inflammation (erythrocyte sedimentation rate (ESR) = 83 mm/h), normal white blood cell count and normal creatine kinase level. Plain radiographs were normal, and there were no signs of thrombophlebitis at Doppler ultrasound. magnetic resonance imaging (MRI) showed diffuse enlargement and an oedematous pattern of the adductors, vastus medialis, vastus intermedius and sartorius of the right thigh. The patient's symptoms improved dramatically, making biopsy unnecessary, and a diagnosis of diabetic muscular infarction was reached. Idiopathic muscular infarction is a rare and specific complication of diabetes mellitus, typically presenting as a severely painful mass in a lower limb, with high ESR. The diabetes involved is generally poorly controlled longstanding Type 1 diabetes with established microangiopathy. Differential diagnoses include deep vein thrombosis, acute exertional compartment syndrome, muscle rupture, soft tissue abscess, haematoma, sarcoma, inflammatory or calcifying myositis and pyomyositis. In fact, physician awareness should allow early diagnosis on the basis of clinical presentation, routine laboratory tests and MRI, thereby avoiding biopsy and its potential complications as well as unnecessary investigations. rest, symptomatic pain relief and adequate control of diabetes usually ensure progressive total recovery within a few weeks. Recurrences may occur in the same or contralateral limb.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/13. diabetes mellitus associated with atypical antipsychotic medications: new case report and review of the literature.BACKGROUND: Since the introduction of atypical antipsychotic medications, beginning with clozapine in 1990, several case reports in the psychiatric literature have suggested that they might be associated with new onset of diabetes mellitus as well as with diabetic ketoacidosis. methods: We report the case of a 38-year-old patient with schizophrenia who suddenly developed diabetes mellitus and ketoacidosis 12 months after starting olanzapine. Similar cases in the literature were found through a medline-assisted search using the key words "schizophrenia," "diabetes mellitus," "ketoacidosis," and "adverse drug reaction." RESULTS: Including this case, 30 patients have been reported in the literature to have developed diabetes or have lost diabetic control after starting clozapine, olanzapine, or quetiapine. Twelve of these 30 developed diabetic ketoacidosis. Two limited quantitative studies have added evidence toward this association. CONCLUSION: Although a causal relation has not been definitively proved, the number of cases reported in the literature suggests there might be an association between atypical antipsychotic medications and diabetes mellitus. Primary care physicians who care for patients with schizophrenia should be aware of this possible association.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/13. Severe degree of hyperglycaemia: insights from integrative physiology.We illustrate how the application of principles of integrative physiology at the bedside can reveal novel insights that have been largely overlooked to this day. In this didactic exercise, modern-day physicians seek an imaginary medical consultation with Professor Sir Hans Krebs because of an unusual finding in his area of expertise: a very severe degree of hyperglycaemia. Although Professor Krebs is restricted to data prior to world war ii, this does not prevent him from making novel discoveries. First, he illustrates how an occult factor, rapid absorption of glucose from the intestinal tract, was a critical feature in explaining the basis of the severe degree of hyperglycaemia without obvious ketoacidosis in a 16-year-old patient with type 1 diabetes mellitus in poor control. Second, by examining simple principles of renal and gastrointestinal physiology in a quantitative fashion, Professor Krebs speculates as to how cerebral oedema might occur before therapy in a patient with a severe degree of hyperglycaemia. We hope that readers and educators will appreciate the value of applying principles of integrative physiology in a quantitative fashion at the bedside.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/13. Hypothalamopituitary deficiency and precocious puberty following hyperhydration in diabetic ketoacidosis.We report on a 5-year-old child who survived an intracerebral crisis, following ketoacidosis-revealing diabetes (DKA), with visual impairment due to a vascular occipital lesion. Two and 4 months after the initial episode, a unique hypothalamopituitary disorder consisting in GH, ACTH, TSH deficiencies and central precocious puberty, was detected. Cranial magnetic resonance images showed no visible lesion in the hypothalamopituitary region. The most likely hypothesis is the ischemia of hypothalamopituitary and occipital regions following possible cerebral edema after hyperhydration. She survived with low visual acuteness and received a combined replacement therapy for the neuroendocrinological deficiencies. This case emphasizes that the rehydration at the initial period of DKA is critical, especially when risk factors for cerebral edema are present (young age, marked hyponatremia). The neuroendocrinological consequences of acute cerebral edema are rare, but physicians must be attentive in survivors of these accidents.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/13. diabetes mellitus and autonomic dysfunction after vacor rodenticide ingestion.A case of N-3 pyridylmethyl-N' 4 nitrophenyl urea (Vacor) rodenticide poisoning in a 52-year-old man is presented. Vacor is structurally related to alloxan and streptozotocin, agents that have been used extensively to produce diabetes mellitus in laboratory animals. Seven days after ingestion of Vacor, the patient presented in diabetic ketoacidosis complicated by postural hypotension and adynamic ileus. The patient recovered from ketoacidosis but has continued to require insulin. With infusion of arginine, glucagon rose from 185 to 650 pg./ml. and c-peptide from 0.5 to 3.4 ng./ml. Six weeks after onset of diabetes, no anti-islet-cell antibodies were detected. Muscle capillary basement membrane thickness on electron microscopy was found to be 1,918 /- 194 A. The absence of hyperglycemia after Vacor ingestion should not lead to complacency on the part of the attending physician. The patient must be observed closely for development of ketoacidosis and treated prophylactically with nicotinamide, the suggested antidote.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/13. Endogenous endophthalmitis and disseminated intravascular coagulation complicating a klebsiella pneumoniae perirenal abscess in a patient with type 2 diabetes.We describe a 56-year-old woman with type 2 diabetes complicated by a Klebsiella pneumoniae perirenal abscess. The patient further developed incipient diabetic ketoacidosis, disseminated intravascular coagulation, and endogenous endophthalmitis. Occurrence of the latter as a metastatic infection from perirenal abscess caused by this organism is very rare, and we know of no previously reported patient with the additional occurrence of disseminated intravascular coagulation. Since prompt intravitreal antibiotic administration is needed, physicians should be aware of these rare but severe complications of K pneumoniae infection, especially in patients with poorly controlled diabetes.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/13. diabetic ketoacidosis and pregnancy.This paper describes the clinical course of a young diabetic primigravida who presented to her physician with vomiting and abdominal pain. Despite the conventional doses of intravenous fluid and insulin that were used to treat her suspected diabetic ketoacidosis, she remained severely acidotic and developed increasing abdominal pain. Two hundred twenty units of regular insulin over a 5-hour period were required to reverse the lipolysis, acidemia, and abdominal pain, which characterized her severe episode of diabetic ketoacidosis. This discussion emphasizes the importance of insulin in the reversal of the hyperglycemia and acidosis that accompany a diabetic crisis. The roles of bicarbonate, phosphorous, magnesium, insulin, potassium, and fluids are discussed along with conditions such as pregnancy, infection, pancreatitis, and abdominal pain, which can complicate the management of diabetic ketoacidosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/13. Necrotizing fasciitis precipitating diabetic ketoacidotic coma.Necrotizing fasciitis is a rapidly spreading infection of the subcutaneous tissue and fascia; diabetes mellitus appears to be the most frequent underlying disease. early diagnosis and immediate aggressive surgical therapy are paramount to curtail morbidity and mortality, but diagnosis is often difficult and unnecessarily delayed. We describe a case of necrotizing fasciitis precipitating diabetic ketoacidotic coma where correct diagnosis was not made until the 14th hospital day. We stress the fact that physicians caring for critically ill patients should be keenly aware of the possibility of necrotizing fasciitis when tending diabetic patients with unexplained fever; failure to recognize the disease can have devastating results. Finally, we believe this to be the first reported case of diabetic ketoacidotic coma precipitated by necrotizing fasciitis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/13. Factitious brittle diabetes mellitus.Five patients are described in whom factitious disease was the cause of brittle type I diabetes mellitus. The patients were referred from throughout the united states because their physicians had been unable to establish the reason for recurrent hospitalizations for diabetic ketoacidosis or coma. In three of the patients, unexplainable signs, symptoms, and/or laboratory results lead to the diagnosis of factitious disease. In the two remaining patients, long-term follow-up was necessary before a factitious cause was established. These five patients exemplify the extraordinary measures that some patients will utilize to continue as a "patient" rather than return to a normal lifestyle.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/13. Rhinocerebral mucormycosis: three case reports and subject review.Rhinocerebral mucormycosis (RCM) in the diabetic patient can be a particularly aggressive and devastating disease. The emergency physician will typically see patients with RCM in its earliest stages masquerading as a variety of other, less serious diseases. early diagnosis is the key to a successful outcome. Three such cases seen in the emergency department are reviewed with attention to their initial clinical presentation and treatment. In addition, the historical, pathophysiologic, clinical, and therapeutic aspects of RCM are reviewed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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