Med Journal March 2021 Final 2 - Page 10

Scientific Article by Shipra Bansal , MD 1 , Matthew S . Bradley , MD 2

Assistant Professor , Pediatric Endocrinology , Arkansas Children ’ s Hospital , Dept . of Pediatrics , Section of Pediatric Endocrinology , UAMS 2 Pediatrics Resident , Dept . of Pediatrics , UAMS

Sudden Weight Gain and Edema in 24 hours in a Patient with Type 1 Diabetes


Subcutaneous insulin initiation , or an increase in insulin doses , can sometimes result in a transient form of generalized or localized swelling called insulin edema . This is uncommon but is not an allergic reaction to insulin and does not require discontinuation of insulin therapy . An increased awareness among clinicians for this condition will allow them to provide reassurance to patient / families to assist with continued adherence to diabetes treatment plans , especially insulin therapy . Due to lack of specific diagnostic laboratory parameters , this case walks through obtaining relevant medical history and exclusion of other causes of localized or generalized edema .

Case Report
A 19-year-old female with Type 1 Diabetes ( T1DM ) presented to our Arkansas Children ’ s Hospital emergency room with complaints of sudden onset , generalized edema with ~ 10-pound weight gain over the past 24 hours .
Swelling had started in both feet and had progressively worsened proximally to her knees , and she complained of some puffiness of hands , feet and abdomen . Review of symptoms was positive for episodic chest pain , with difficulty breathing and palpitations not associated with exercise / activity . She denied cough , nausea , vomiting , abdominal pain , jaundice , puffy eyes , decreased urine output , decreased appetite . Her usual medication included only insulin aspart via an insulin pump . She had recently been discharged following a week-long stay for severe diabetic ketoacidosis ( DKA ) at an outside hospital . She reported that her diabetes control over the past couple of years had significantly worsened since she moved out of her parents ’ home . She had been poorly compliant with her diabetes care , as she had not been taking her insulin for ~ 5 days before presentation . On discharge after her recent hospitalization , she was prescribed potassium supplementation for one week along with an oral antibiotic ( Cefalexin ) for gluteal abscess . Since discharge , she had more closely followed her diabetes care recommendations , as well as continued potassium supplements and Cephalexin as directed . Her immediate family was also more involved in her diabetes care , which she appreciated and wanted to continue .
Upon evaluation , she was afebrile with normal vital signs , well hydrated . BMI 19.27kg / m2 ( 25 th percentile for age ). Her heart sounds were normal , no added sounds , good air entry bilaterally with normal breath sounds . There was no hepatosplenomegaly or ascites . She had pitting edema up to the knees but no objective hand , face , periorbital or abdominal wall swelling . No rashes , tenderness , induration noted except healing abscess in the gluteal cleft without active drainage .
Laboratory studies revealed mild anemia with normal WBC count and platelets . Her electrolytes were normal but had mild hypoalbuminemia [ albumin 3.5 ( lab reference for age 3.7-5.6 )]. Her fingerstick glucose is 170mg / dL ( 8.5mmol / L ) that was in range for her diabetes , but her glycosylated Hemoglobin ( HbA1c ) was 12.1 % ( indicative of poor control , target HBa1c < 7.5 %). Urinalysis revealed mild proteinuria [ 30mg / dL ( normally negative )], mild glucosuria [ 300 mg / dL ( normally negative )] with trace ketones . Her chest radiograph ( two views ), electrocardiogram , cardiac echocardiogram , ultrasound of the bilateral kidneys as well as lower extremity did not reveal any abnormality . Her thyroid function was noted as normal , too .
The diabetes team was consulted and recommended continuation of insulin therapy . Due to continued edema and concern for chest pain , she received two doses of furosemide ( 30 milligrams intravenous ) with satisfactory diuresis and resolution of her edema . Her insulin doses were titrated based on her blood sugars , and she continued antibiotics for gluteal abscess with good response . With improvement in her condition , she was able to be discharged home on third day of hospitalization .
Upon outpatient diabetes clinic follow up in a month , she was doing well and noted with improved glycemic control and with resolution of her symptoms , including the excess fluid gain .
Insulin edema is a diagnosis of exclusion , usually presenting either at initiation of insulin therapy or with escalation in treatment within one to 10 days . 1 , 2 It is a rare and often unrecognized complication of insulin therapy , although described almost a century ago , 3 and is not an allergic reaction to insulin . 4 The severity of edema varies from being subclinical and can go unnoticed to being mild-moderate ( as seen in our patient ) or present with pleural effusions , ascites , or even cardiac failure . 5 This edema can occur both with T1DM 1 , 2 and as Type 2 Diabetes Mellitus , 6 though case reports of insulin edema is also reported with Cystic Fibrosis related diabetes . 7 Many of the cases reported in literature have occurred in children who are lean , with a BMI at the low range of normal . 8
When initially describing this condition in 1929 , Leifer proposed the acute onset edema to be due to rapid retention of tissue fluid secondary to glycogen deposition . 3 Newer proposed etiologic mechanisms include an increase in renal proximal tubule sodium reabsorption due to direct anti-natriuretic effect
202 • The Journal of the Arkansas Medical Society www . ArkMed . org