Injuries IN type 1 diabetes – a

true challenge

Daniel-Tudor Cosma, MD

Center for Diabetes, Nutrition and Metabolic diseases Cluj-Napoca

Romania diabetes futsal team physician
• 32-years old male

Located profound Insidious onset

Pain in the left

groin area

Aggravated by any PA,

especially external
9/10 – VAS
rotation of the left lower
limb
 Family history:

• Hypertension
Maternal
grandmother

• Alcoholic cirrhosis
Father • Hepatocellular carcinoma (died at the age of 51)

• Gallbladder dyskinesia
Mother
Past medical history (1)
18-years old – T1DM
basal bolus regimen with glargine and aspart insulin
(CF=40mg/dl, ICR=1:10)

31-years old - Dawn phenomenom

Insulin pump therapy with aspart (CF=40mg/dl, ICR=1:10)

32-years old – Baker cyst and minimal hydarthrosis of the

anterior compartment of the right knee
Flat feet

6 months before admission: Left pubalgia

- rest (6 weeks);
- 2 cycles (7 days) of NSAID (Celecoxib 90mg/day) at one month’s interval
Past medical history (2)

Baker cyst of the right knee

(Ultrasound: transversal view)

Baker cyst of the right knee

(Ultrasound: longitudinal view)
Social History

Sales agent

Occasionally

Amateur soccer/futsal player

(goalkeeper)

Occasionally
He lives in urban area with his fiancée

11 years: 3-5 cigarettes/day

Glycemic testing: 3-4 times daily; Gave up 2 years ago
24-hour Dietary Recall (without nutritional counseling)

No PA PA (120 minutes) ∆ (PA –No PA)

Kcal/day 2458 3951 1493

Carbs (g) 324 425 101

Fats (g) 72 163 91

Proteins (g) 114 173 59

No. of meals 3 3

No. of snacks 3 2

Mean BG (mg/dl) 151.66 204.14 52.48

Insulin dose 0.589 0.397 -0.192

(IU/kg)
No. of hypos 0 1
At admission: Basal rate=25.7IU/day; boluses=35IU/day

1.6

1.4

1.2
Basal rate (IU/h)

0.8

0.6

0.4

0.2

0
0 5 10 15 20 25 30

Time (hours)
Physical examination:

• Anthropometric indexes: H=1.85m, W=89kg, BMI=26kg/m², W=105cm

• Skin:
- dry mucous membranes

• Bones and joints examination:

- flat feet;
- bilateral hallux valgus
- cracking sounds on knees mobilization

▪ Cardiovascular system examination:

- BP=120/80 mmHg; Pulse=70 b/min
- rhythmic cardiac sounds

• Abdominal examination:
- lipohypertrophy due to insulin therapy under umbilical area
- distended abdomen due to fat tissue
Presumptive diagnoses
 Type 1 DM

 Lipohypertrophy due to insulin therapy under umbilical area

 Left pubalgia

 Bilateral hallux valgus

 Flat feet

 Baker cyst
 Laboratory assessment
HGB=15.1g/dl (12-17.4) A1c=6.7%

RBC=4.77x1012/L (4-5.5) Gl=173mg/dl

HCT=41.9% (36-52) COL total= 159mg/dl (150-220)

PLT=273 x 109/L (150-400) TG=51mg/dl (50-160)

NEUT=45.6% (50-75) HDL col=55mg/dl (35-80)

LYMPH=44.3 (20-40) LDL col=94mg/dl (60-160)

ESR=2mmh (6-12)

CRP=0.4 (<0.6)
 Doppler exam:
ABI right tibial=1; ABI left tibial=1.3;
ABI right dorsali pedis=1.3; ABI left dorsalis pedis=1.3

 Fundoscopy: no diabetic retinopathy

 EKG: Sinus rhytm; HR=64b/min; no pathological findings

 Sudoscan test: moderate peripheral autonomic neuropathy

4% risk for cardiac autonomic neuropathy

 Cardiosys test: 4 (Borderline: 3-5)

 AGE Reader: 2.23 (significant cardiovascular risk)

Cardiosys
 Neurology consult
Dg:
- Mild peripheral diabetic neuropathy
Rec:
- Benfotiamine 100mg 1-0-1/day; α-lipoic acid 600mg 1-0-0/day

 The assessment of knowledge regarding insulin therapy, carbs

counting and diabetes management during exercise revealed a well-
educated patient
X-rays
CT scan (1)
CT scan (2)
Presumptive diagnoses
 Type 1 DM complicated by mild peripheral diabetic
polyneuropathy
 Moderate peripheral autonomic neuropathy
 Lipohypertrophy due to insulin therapy under
umbilical area
 Partial tear of the left rectus femoris
 Avulsion fracture of the AIIS
 Early right coxarthrosis
 Bilateral hallux valgus
 Flat feet
 Baker cyst
Evolution during hospitalization (1)
 Physical therapy program – 2 weeks;
 Treatment with:
Symptomatic therapy Pathogenetically orientated therapy for DN
Celecoxib 30mg 0-1-0/day Benfotiamine 100 1-0-1/day

Tramadol+Acetaminophen 37.5/325mg 1-0-1/day α–lipoic acid 600mg 1-0-0 vials/day

Ketoprofenum gel 2.5% 2 application/day

6/10 VAS

Betamethasone 1ml (7mg) 1 injection

Evolution during hospitalization (2)
Evolution during hospitalization (3)

4th day: 6th day: 8th day:

Preventive measures: - Persistent hyperglycemia - Persistent hyperglycemia
- ↑ BR to 120% - ↑ BR to 140% - ↑ BR to 160%
- Increased prandial boluses - Increased prandial boluses - Increased prandial boluses
with 2 IU with 4 IU with 5 IU

10th day: 13th day:

- Persistent hyperglycemia - BG normalization
- ↑ BR to 120% - Previous BR and prandial
- Increased prandial boluses boluses (CF=40mg/dl;
with 2 IU ICR=1:10)
Evolution during hospitalization (4)
Day BR BR (%) Boluses Boluses TDI (IU) Dose/ Max Gl Mean Gl
(IU/day) (IU/day) (%) body (mg/dl) (mg/dl)
weight
(IU/kg)
1 25.7 42 35 58 60.7 0.682 210 135

4 30.84 43 41 57 71.84 0.807 280 178

6 35.98 43 47 57 82.98 0.932 317 172

8 41.12 45 50 55 91.12 1.023 456 197

10 30.84 43 41 57 71.84 0.807 243 142

Diagnoses at discharge
 Type 1 DM complicated by mild peripheral diabetic
polyneuropathy
 Moderate peripheral autonomic neuropathy
 Lipohypertrophy due to insulin therapy under
umbilical area
 Partial tear of the left rectus femoris
 Avulsion fracture of the AIIS
 Early right coxarthrosis
 Bilateral hallux valgus
 Flat feet
 Baker cyst
Recommendations at discharge

1. Diet 2000Kcal/day with 268g CH (55%) and 30% fats.

2. Insulin therapy with aspart insulin through insulin pump adjusted
according to carbs ingested using ICR=1:10 and CF=40mg/dl.
3. Treatment with: Ketoprofenum gel 2.5% if needed.
4. Diabetes consult every 3 months.
5. Fundoscopy, foot exam and ACR every year.
5. Resume the physical therapy program at home.
6. Plantar support.
Evolution after discharge

Significant improvement in pain symptoms for 6 months

0/10 – at rest; 2/10 – during PA on VAS

Improvements in glycemic control

A1c evolution: 6.7% - 6.5% – 6.4%

MRI - to confirm the muscle tear and establish further

treatment
Discussions (1)

Hwang, Jessica L., and Roy E. Weiss. “Steroid-Induced Diabetes: A Clinical and Molecular Approach to Understanding
and Treatment.” Diabetes/metabolism research and reviews 30.2 (2014): 96–102. PMC. Web. 27 Oct. 2017.
Discussions (2)

Liu et al.: A practical guide to the monitoring and management of the complications of systemic
corticosteroid therapy. Allergy, Asthma & Clinical Immunology 2013 9:30.
Discussions (3)
Discussions (4)
Discussions (5)

All 10 studies reviewed showed significant but transient increases in post injection BGL with peak
individual blood sugars as high as 518 mg/dL. Mean blood sugar elevations reported ranged from 125
to 320 mg/dL. Most studies found time to peak post injection BGL occurred within 1 to 5 days, and
BGL returned to baseline in less than 24 hours up to 10 days.
None of the studies specifically reported postprandial BGL.
Patients with T1DM or insulin-dependent diabetes (IDDM) had higher postinjection BGL than those
with T2DM not requiring insulin in 2 studies.
No adverse events were reported in any of these studies.
However, this risk needs to be balanced with possible benefits of the injection, including relief of
pain, increased ability to perform physical activity with decreased risk of complications from DM,
and improved quality of life, as well as possible avoidance of surgery.
Discussions (6)
Discussions (7)
Particularities of this case
 compliant and well educated type 1 diabetic on insulin pump;

 significant and prolonged hyperglycemia after one injection of

Betamethasone requiring important increasing in basal rate and
boluses in order to maintain BG within targets

 improvement in pain symptoms lasting for months;

 recurrence of the symptoms might be due to the muscle lesions

THANK YOU!