Medical Case Reports

Description

Diabetes mellitus is a growing concern all over the world. There are no many published literature available documenting the effectiveness of Ayurveda intervention on diabetes mellitus. This report is about a case in which successful reversal of diabetes mellitus was achieved in a patient who reported with glycosylated Hb percentage as high as 14.87%. The patient had classical symptoms of diabetes mellitus viz. excessive thirst, fatigue and frequent urination. His fasting blood glucose level was 346 mg/dl and post prandial glucose level of 511 mg/dl. Furthermore his HbA1C was as high as 14.87%, thus diagnosed with diabetes mellitus. Based on his specific clinical symptoms the patient was diagnosed with Kaphaja Prameha. Treatment was given according to classical Ayurveda intervention for Kaphaja Prameha. The patient responded well to the treatment. His HbA1C reduced to 6.05% in a span of eight months. The case report shows the effectiveness of Ayurveda intervention in diabetes mellitus. It is limited in its scope as it is a case report, nevertheless this can be taken up as an information that may lead to new research and advances in the field of clinical practice in Ayurveda. Sodium/Glucose cotransporter 2 (SGLT2) inhibitors have demonstrated a class effect in improving serum magnesium levels in patients with diabetes.

Cystic Fibroses

Additionally, recent reports have shown their promising beneficial effects in the treatment of refractory hypomagnesemia in patients with diabetes. However, their role in treating hypomagnesemia in patients without diabetes remains unexplored. Here, we report 4 cases of severe and refractory hypomagnesemia that showed dramatic improvement after initiating SGLT2 inhibitors in patients without diabetes. Case 1 had calcineurin inhibitor-associated severe hypo magnesemia. Cases 2, 3, and 4 had refractory hypomagnesemia associated with platinum-based chemotherapy with or without gastrointestinal losses. Case 1 was able to withdraw from highdose oral magnesium supplementation. Cases 2 and 3 achieved independence from intravenous magnesium supplementation, whereas case 4 had decreased intravenous magnesium requirements. All the cases demonstrated sustainably improved serum magnesium levels.

Withdrawal of SGLT2 inhibitors in case 4 resulted in worsening serum magnesium levels and intravenous magnesium requirements. The extra glycemic benefit of this group of medications not only suggests the need for further studies to better understand the effect of SGLT2 inhibitors on magnesium homeostasis but also supports expanded use in a larger patient population. Hypertriglyceridemia is a rare but potentially severe complication of pregnancy. It is seen in women with inherited lipid disorders, thyroid disease, nephrotic syndrome, diabetes and is associated with certain medication. Hypertriglyceridemia can cause pancreatitis, pre-eclampsia and fetal compromise. Treatment is often challenging-many medications are not approved during pregnancy and much of the evidence comes from small case reports and case series. Here was present the case of a lady with type 2 diabetes and hypertriglyceridemia, outline our treatment plan and progress and review the literature. Cystic Fibroses (CF) is incurable and chronic, causing severe multisystem damage and long-term complications. The most prominent extra pulmonary long-term complication is CFrelated diabetes, which is the most reported form of diabetes in individuals with cystic fibrosis. Here we present the first case of an individual with cystic fibrosis who developed type 2 diabetes due to obesity rather than CF-related diabetes.

Case of Myonecrosis

The type 2 diabetes went into remission due to extreme weight loss after gastric bypass surgery. To our knowledge, this case is also the first report describing the effect of bariatric surgery in a patient with CF. This case demonstrates that patients with CF may present with type 2 diabetes instead of CFrelated diabetes. Differential diagnosis of these two types of diabetes is essential for optimal treatment and quality of life. Gestational Diabetes Insipidus (GDI) is a rare complication of pregnancy thought to be due to increased vasopressin produced by the placenta. It typically occurs at the end of the second or in the third trimester. This report describes a case of GDI diagnosed postpartum in the setting of newly diagnosed superimposed preeclampsia. A 39-year-old Hispanic woman presented ten days postpartum with a persistent headache and elevated blood pressures in the setting of a history of chronic hypertension, meeting criteria for superimposed preeclampsia. Repeat lab work was notable for mild elevation of liver function enzymes. Despite normalization of blood pressures, her headache persisted and further workup revealed polyuria, suspected to be vasopressin’s-induced diabetes insipidus. The patient was started on oral desmopressin with improvement of polyuria and symptoms. The incidence of diabetes mellitus is increasing rapidly, and this condition often results in severe complications. One such complication, diabetic Oculomotor Nerve Palsy (ONP) that can lead to significant impairment of visual function is increasingly recognized. However, there are few reports in the literature on the treatment of diabetic ONP. In the present case, the use of needling a selection of local and distal acupoints showed promising results for the treatment of diabetic ONP. We also present a brief literature review related to this case. Very Long-Chain Acyl-COA Dehydrogenase Deficiency (VLCADD) is a rare autosomal recessive disorder of fatty acid metabolism. Its clinical presentation includes hypoketotic hypoglycemia and potentially life-threatening multi organ dysfunction. Therefore, the cornerstone of management includes avoiding fasting, dietary modification, and monitoring for complications. The cooccurrence of type 1 Diabetes Mellitus (DM1) with VLCADD has not been described in the literature. Diabetic myonecrosis is a rare complication of poorly controlled diabetes mellitus which commonly affects the thigh and is managed conservatively. Spontaneous ischemic necrosis of muscle is noted without a reduction in vascular supply. Pyomyositis caused by Staphylococcus aureus infection is another rare complication. Atypical presentation of myonecrosis and pyomyositis can occur in the form of simultaneous or sequential involvement of multiple muscle groups. We present a rare case of myonecrosis with pyomyositis in a 39-year-old male patient with a background of type 2 diabetes mellitus who presented with a 5- day history of worsening pain of the right thigh radiating to the right ankle, associated with groin swelling and fever. It is important for clinicians to have a low threshold of suspicion of this rare condition due to the other diverse and similar diagnoses, as well as to prevent further complications and morbidity. A 14-year-old male with a known diagnosis of VLCADD presented with vomiting, epigastric pain, hyperglycemia, and high anion gap metabolic acidosis. He was diagnosed with DM1 and managed with insulin therapy while maintaining his high complex carbohydrate, low long-chain fatty acids diet with medium-chain triglyceride supplementation. The primary diagnosis VLCADD makes the management of DM1 in this patient challenging as hyperglycemia related to the lack of insulin puts the patient at risk of intracellular glucose depletion and hence increases the risk for major metabolic decompensation. Conversely, adjustment of the dose of insulin requires more attention to avoid hypoglycemia. Both situations represent increased risks compared to managing DM1 alone and need a patient-centered approach, with close follow-up by a multidisciplinary team.