Category: Diabetes/Prediabetes/Hypoglycemia

WHEN DIABETES HURTS

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Treatment induced neuropathy or insulin neuritis is a painful, autonomic neuropathy that appears after abrupt correction of hyperglycemia in patients with history of elevated glucose levels. It is a rare iatrogenic complication of diabetes. Patients usually present with significant pain and autonomic dysfunction after rapid glycemic correction. The incidence increases when glycated hemoglobin decreases at least two percent within 3 months of treatment, and appears 4 to 8 weeks after initiation of insulin therapy.  We present a case of treatment induced neuropathy after rapid improvement of hyperglycemia.


Methods : none


Results :

30 y/o man without medical history presented to the ER with polyuria, polydipsia and general malaise. Laboratories and physical examination were consistent with diabetes ketoacidosis. Patient was admitted to ICU and treated accordingly, later diagnosed with Type 1 Diabetes Mellitus. At the time of diagnosis, patient’s glycated hemoglobin was 15.7%. He was placed on basal bolus insulin therapy and lifestyle changes. Patient’s glycated hemoglobin decreased to 9.2% eight weeks after starting insulin therapy. At that time, patient developed bilateral leg tingling, numbness and burning sensation in his feet. He was treated with gabapentin and tramadol without improvement. Patient’s glucose levels continued improving until A1c decreased to 5.8%. Still, lower extremity symptoms persisted. Electromyography study confirmed sensory motor polyneuropathy. Therapy was optimized to pregabalin with significant symptomatic improvement.


Discussion :

Insulin neuritis is a rare acute neuropathy difficult to distinguish from other polyneuropathies. Gibbons and Freeman proposed three diagnostic criteria including acute onset of neuropathic pain, decrease of at least 2% of HbA1c in 3 months and onset of neuropathic pain within 8 weeks of lowering A1c levels. Our patient met all these criteria. High suspicion index is required for appropriate diagnosis and management. Definitive treatment for this condition remains unknown. Literature suggest that pain and sensory symptoms improve after cessation or insulin therapy, but there is no consensus regarding its management. However, in those patients that are insulin dependent, discontinuation of insulin is not an option. Pain management should be provided with the principal objective of symptoms reduction.  


Conclusion : Insulin neuritis carries a favorable outcome overall. This condition can be prevented with less aggressive correction of hyperglycemia.

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Yanerys Agosto-Vargas

Endocrinology Fellow
San Juan City Hospital
Canovanas, Not Applicable, Puerto Rico

Second year fellow at San Juan City Hospital. She is always willing to learn.

Michelle Mangual- Garcia

Program Director
San Juan City Hospital
SAN JUAN

Program Director at San Juan City Hospital

Ernesto Sola-Sanchez

Attending Physician
San Juan City Hospital

Recently graduated from our institution who rapidly become key faculty member.