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Displaying 1 - 10 of 138 in Annals of Internal Medicine: Clinical Cases

Mixed Diabetes (Type 1 and Type 2) in an Adolescent With Both Obesity/Insulin Resistance and Autoimmune Markers | Annals of Internal Medicine: Clinical Cases

A 14-year-old boy with obesity (body mass index 30.5 kg/m²) presented with polyuria and polydipsia and severe hyperglycemia (hemoglobin A1C 15.5%). Islet autoimmunity was strongly positive (anti-glutamic acid decarboxylase 466 IU/mL; islet-cell antibody 61.8 U/mL), yet β-cell function was preserved (C-peptide 3.6 ng/mL) with insulin resistance (Homeostatic Model Assessment of Insulin Resistance score 4.6), acanthosis nigricans, and obesity. This discordant presentation challenged classification as type 1 or type 2 diabetes and supported a mixed/overlap (“double/hybrid”) phenotype. Basal insulin was administered in addition to pioglitazone/metformin in combination with close follow-up and cardiometabolic risk assessment.

Acute Thigh Pain in a Patient With Diabetes Mellitus: A Rare Case of Diabetic Myonecrosis | Annals of Internal Medicine: Clinical Cases

Diabetic myonecrosis (also known as diabetic muscle infarction, or DMI) is a rare complication of poorly controlled diabetes, with fewer than 200 discrete cases reported in the English language medical literature over the past 60 years. In most published cases, diabetic myonecrosis occurs concurrently with other micro/macrovascular diabetic sequelae (e.g., nephropathy). Here, we describe a case of a patient with DMI without nephropathy, whose presentation was otherwise pathognomonic for DMI. We share this case to increase clinician awareness of this uncommon condition and to highlight the diagnostic and treatment considerations to keep in mind when managing suspected DMI, as choice of treatment can dramatically affect clinical course.

Euglycemic Diabetic Ketoacidosis Related to SGLT2 Inhibitor Use in a Patient With Cobalamin C Deficiency and Diabetes | Annals of Internal Medicine: Clinical Cases

A 24-year-old woman with cobalamin C deficiency (CblCD), autoimmune thyroiditis, and recently diagnosed diabetes mellitus presented with weight loss, emesis, and abdominal pain. She had been placed on sodium-glucose cotransporter inhibitor (SGLT2i) therapy because of metformin intolerance, with the addition of a dipeptidyl peptidase-4 inhibitor. Biochemical analyses demonstrated severe acidosis, initially attributed to CblC-associated metabolic decompensation. Subsequent evaluation led to the diagnosis of SGLT2i-induced euglycemic diabetic ketoacidosis in a patient with type 1 diabetes mellitus. This case highlights the importance of assessing for insulin deficiency when evaluating acidosis and the management challenges of common diseases in adults with inherited metabolic disorders.

Why So Salty? Transient Diabetes Insipidus After Discontinuation of Vasopressin | Annals of Internal Medicine: Clinical Cases

In recent years, vasopressin has been increasingly used as an early treatment of vasopressor-refractory septic shock. In this article, we describe 2 episodes of transient diabetes insipidus after vasopressin for the treatment of septic shock was discontinued, which adds to a modest number of case studies reporting the same phenomenon. With the anticipated continued use of vasopressin in intensive care units, it can be expected that this adverse effect will occur with some frequency. Awareness and early recognition of this phenomenon can lead to prompt diagnosis and treatment.

Unexpected Therapeutic Effect of GLP-1 Receptor Agonists in Patients With Refractory IBS-D: A Case Series | Annals of Internal Medicine: Clinical Cases

Irritable bowel syndrome with diarrhea (IBS-D) is a common functional gastrointestinal disorder. It is primarily caused by increased intestinal transit. GLP-1 receptor agonists (GLP-1 RAs) are widely used for obesity and diabetes management. They have been shown to decrease intestinal motility as a side effect. We present a 67-year-old woman and a 23-year-old woman, both with long-standing, debilitating IBS-D. Both achieved a 22.7-kg weight loss with GLP-1 RA use. They also reported resolution of diarrhea and improved quality of life. This case series suggests potential therapeutic benefits of GLP-1 RA use in hypermotility associated with IBS-D.

An Unusual Case of Hyperosmolar Hyperglycemic State Complicated by Bilateral Occipital Lobe Seizures | Annals of Internal Medicine: Clinical Cases

Hyperosmolar hyperglycemic state (HHS) is a complication of type 2 diabetes mellitus (T2DM) marked by hyperglycemia without acidosis. We present a case of a 59-year-old woman with a history of T2DM and migraines who presented with worsening occipital headaches accompanied by visual disturbances. Her glucose level on arrival was 559 mg/dL with a normal anion gap. Magnetic resonance imaging revealed cortical restricted diffusion in the left occipital lobe. An electroencephalogram detected electroclinical focal seizures in the bi-posterior region. This case highlights the importance of both recognizing seizures in HHS and the need to consider alternative diabetes diagnoses for patients with atypical diabetic phenotypes.

Delayed Diagnosis of Genitourinary Tuberculosis Masquerading as Refractory Bacterial Cystitis | Annals of Internal Medicine: Clinical Cases

We report a case of genitourinary tuberculosis in a 34-year-old HIV-negative Filipino woman with diabetes mellitus. She presented with chronic cystitis with only partial response to antibiotics. Diagnosis was delayed owing to nonspecific symptoms and prior fluoroquinolone use, which may have partially suppressed Mycobacterium tuberculosis. Reactivation of tuberculosis may have been facilitated by worsening diabetes. This case underscores the importance of considering genitourinary tuberculosis in patients with risk factors of tuberculosis, persistent urinary symptoms, and sterile pyuria. It also highlights the need for early diagnosis to prevent renal damage.

Euglycemic Diabetic Ketoacidosis in a Patient Post Cardiac Surgery Receiving Continuous Renal-Replacement Therapy | Annals of Internal Medicine: Clinical Cases

Euglycemic diabetic ketoacidosis is an often-underrecognized endocrine emergency. We highlight an unusual presentation of euglycemic diabetic ketoacidosis in a patient with a history of hypertension, type 2 diabetes mellitus, and stage 3b chronic kidney disease who had elective aortic and mitral valve–replacement surgery. She developed acute kidney injury requiring temporary continuous renal-replacement therapy. Despite hemodialysis, the patient had persistent anion-gap metabolic acidosis. Additional evaluation resulted in the diagnosis of euglycemic diabetic ketoacidosis. Successful care in this patient population entails a high index of suspicion, early diagnosis, and appropriate management.

Linagliptin-Induced Pancreatitis | Annals of Internal Medicine: Clinical Cases

Incretin-based medications are well-established agents used for glycemic control in patients with type 2 diabetes mellitus. Of these medications, glucagon-like peptide 1 agonists have a well-known association with pancreatitis. However, controversy still exists about a similar association with dipeptidyl peptidase 4 inhibitors. Linagliptin, in particular, has not been studied thoroughly. Therefore, to the best of our knowledge, we report linagliptin-induced pancreatitis, the fourth case reported in the medical literature, that resolved after stopping the medication and did not recur with the resumption of all of the other patient's medications.

Pneumococcal Endocarditis, Rare but Not Forgotten | Annals of Internal Medicine: Clinical Cases

Pneumococcal endocarditis incidence has significantly decreased since the advent of antibiotics but remains a significant cause of mortality and morbidity in high-risk groups, such as those with heart disease, chronic lung and liver disease, smoking, diabetes mellitus, and immunosuppression. We present a unique case of pneumococcal endocarditis with no clinical stigmata of infective endocarditis that manifested with acute hypoxic respiratory failure and severe aortic regurgitation. A large vegetation on the aortic valve was noted during surgery, with negative blood cultures and aortic valve tissue cultures but positive Streptococcus pneumoniae urinary antigen and polymerase chain reaction (PCR) test on the aortic valve.

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