Insulin Edema Research Articles

6849 Insulin Edema in newly diagnosed T1DM Pediatric Patient

Abstract Disclosure: A. Ansar: None. K. McNerney: None. Background: Insulin edema is a rare complication of insulin therapy, especially in the pediatric populations. The pathogenesis is not fully understood but has been linked to Insulin’s role in renal sodium handling and vascular permeability. It has been seen with the initiation of insulin in newly diagnosed patients or the intensification of insulin therapy in those with poor glycemic control.Clinical Case: A previously healthy 12 year old girl presented to the ED with polyuria, polydipsia and fatigue. She was alert and oriented but had kussmaul breathing. She was tachycardic but all other vitals were appropriate. Lab work up showed that she was in DKA with pH 7.07 and bicarbonate 7 mmol/L. Her corrected sodium and electrolytes were normal. Her HbA1C was elevated at 11.7% (4.0-5.6%). Initial fluid resuscitation was performed with 20 mL/kg NS fluids. She was transferred to our Pediatric ICU and was started on the DKA protocol consisting of intravenous insulin infusion at 0.1 unit/kg per hour and 2-bags of dextrose and non-dextrose containing intravenous fluids. She was given a new diagnosis of Type 1 Diabetes. She was transitioned to subcutaneous insulin 22 hours later with multiple daily injections with insulin lispro and glargine, with total dose of insulin at 0.7 unit/kg per day. She was transferred to the general care floor and received diabetes education while in the hospital. On the fifth day after discharge, patient started complaining of leg tightness, puffiness around her eyes and generalized swelling of both feet. She returned to the ED, where she was found to be hemodynamically stable and normotensive with a blood pressure of 113/54 mmHg. Her weight had increased 8.8 kg from the weight at discharge. Her physical exam was notable facial and bilateral periorbital edema, abdominal distension, and 2+ bilateral non-pitting non-tender edema of both legs extending to her medial malleolus. Neurologic exam was performed which was unremarkable. Work up was performed to rule out other causes of edema, including a complete blood count, electrolytes, kidney and liver function tests, all of which were normal. She received 20 mg of furosemide and was instructed to perform fluid restriction to 1 L/m2/day and sodium restriction to <2 grams per day at home. She followed up in clinic 3 days after her ED visit where her weight had decreased by 4.2 kg and her edema had mostly resolved with only 1+ bilateral non-pitting edema. Her total dose of insulin remained at 0.7 unit/kg per day, with acceptable blood glucose levels at home. Her fluid restriction was discontinued and patient was instructed to follow up as usual, and she had no further edema in follow-up. Conclusion: This was a rare case of a newly diagnosed pediatric patient presenting with Insulin edema, which is essential for clinicians to recognize, so they can identify patients presenting with this uncommon side effect to rule out conditions that may present in a similar manner. Presentation: 6/2/2024

THU388 Insulin Edema Associated With Glargine: A Case Report And Brief Review Of Literature

Abstract Disclosure: J. Wood: None. V. Samji: None. F.S. Celi: None. P. Majety: None. Introduction: Insulin edema is an uncommon and poorly understood complication of insulin therapy in patients with diabetes. We report a patient with type 1 diabetes (T1DM) who developed edema within days of initiating insulin glargine that resolved with discontinuation of this medication. Case Report: A 20-year-old man with no past medical history presented with nausea, vomiting, polydipsia, and a 15-pound weight loss and was noted to have a hemoglobin A1c greater than 14.0%. Diabetic ketoacidosis (DKA) was ruled out and was started on weight-based insulin therapy with glargine and lispro three units with meals. Additional diabetes workup was notable for positive Anti-IA2 antibodies. Blood glucose levels improved prior to discharge. A week after discharge, he complained of swelling of limbs. Patient denied any shortness of breath, cough, chest pain, orthopnea, or nocturnal dyspnea. He was found to have extensive 2+ pitting edema in bilateral feet extending up to his calves. Dorsalis Pedis pulses were 2+ bilaterally. No warmth or erythema of legs was noted. His weight in clinic was 70.2 kg (154.4 lbs), up 11.6 kg (25.5 lbs) ten days post discharge. Evaluation for bilateral pedal edema was performed. Labs were notable for normal liver enzymes, creatinine, glomerular filtration rate and urine albumin levels, ruling out hepatic and renal causes of edema. Thyroid function tests were normal. His presentation was discussed with cardiology and brain natriuretic peptide level was drawn which was also normal. No further cardiac workup was recommended at that time given the patient’s history and lack of other clinical signs or symptoms of heart failure. After ruling out other systemic causes of edema in our patient, a diagnosis of insulin edema was made. Based on prior case reports of glargine associated insulin edema, he was switched from insulin glargine to insulin degludec. He noted significant improvement within 24 hours of switching insulin with a 6.4-pound weight loss in just one day and complete resolution of edema within 3 days. He had no recurrence of edema once glargine was discontinued despite increasing insulin dosing for glycemic control. Conclusion: The pathophysiology of insulin edema is unclear. Insulin’s role in renal sodium handling, vasodilation, and increased vascular permeability, have been postulated as possible mechanisms. Risk factors for developing insulin edema include T1DM, high A1C, high dose of insulin, rapid correction of hyperglycemia, DKA on presentation and poor nutritional status. Additional risk factors for developing insulin edema include thiamine deficiency and an underlying genetic predisposition related to a mitochondrial mutation, although this seems to be rare. Insulin edema is a diagnosis of exclusion. Clinicians should be aware of this rare complication, and its occurrence should be documented and differentiated from other causes of edema. Presentation: Thursday, June 15, 2023

Insulin edema, a little known entity.

Insulin edema is an entity that should be considered in any patient who starts or intensifies an insulin regimen to improve metabolic control. Heart, liver, and kidney problems should always be ruled out beforehand. The exact mechanism is not clear. It is usually self-limiting within a few days and rarely requires specific therapy. It could be prevented with a more progressive improvement in glycemic control avoiding rapid increases in insulin dose. We present the case of two female adolescents with a new diagnosis of type 1 diabetes mellitus with ketoacidosis. A few days after starting treatment with a basal bolus regimen with subcutaneous insulin, edema started and limited to the lower extremities. In both cases, the symptoms resolved spontaneously.

The rare complication of type 1 DM, which is insulin-dependent edema: Four patient case reports presenting with the same clinical manifestation

Insulin is the essential hormone in managing Type 1 Diabetes Mellitus (DM). Severe complications can be seen during treatment. Insulin-dependent edema is a rare complication that can be seen regularly in patients with new diagnoses or poorly controlled diabetes shortly after the start of intensive insulin therapy. It can present itself in various clinical forms, from minimal peripheral edema to heavy pericardial, pleural edema and even heart failure. Although insulin-dependent edema has been known for a long period, the number of cases reported in the literature is very few. We are reporting four cases with poorly controlled type 1 diabetes that developed insulin edema.

PSUN264 Insulin Edema: A rare side effect of Intensive Insulin Therapy

Abstract Insulin therapy associated generalized edema is a rare entity. The true incidence is unknown. It has been reported mostly in patients with poorly controlled diabetes mellitus started on intensive insulin regimens. The severity ranges from mild lower extremity swelling to anasarca. Management is primarily supportive with salt restrictions, diuretics and if possible, reduction of insulin doses. We present a case of a 39-year-old African American woman who developed generalized edema after initiation of insulin. She had history of gestational diabetes and presented to the endocrinology clinic to establish care after being hospitalized with Diabetic Ketoacidosis (DKA). She was diagnosed with diabetes mellitus initially during her pregnancy two years prior and was treated with insulin. After pregnancy, she was lost to follow up. She was then admitted to the hospital with severe DKA and was discharged on multiple daily injections of insulin. On the initial encounter in clinic, the patient endorsed developing abdominal distension and lower extremity swelling with insulin use previously so she was not using insulin consistently. Her physical examination was unremarkable. Lab work was significant for hemoglobin A1C of >15%, C-peptide 0.9 ng/mL (1.1-4.4 ng/mL), islet cell antibody 0.09 nmol/L (<0.02 nmol/L), glutamic acid decarboxylase antibody 0.40 nmol/L (<0.02 nmol/L). Her kidney and liver function were normal. She had normal thyroid function and cortisol levels. Her echocardiogram revealed normal cardiac function and she had non proliferative diabetic retinopathy on retinal exam. The patient was started on insulin and a continuous glucose monitor was placed to assess her glycemic patterns. Three days after starting insulin, she developed generalized body swelling involving face, abdomen, and lower extremities. The patient was advised to cut back on salt and started on low dose furosemide. On follow up one month later, her abdominal swelling had improved however she still had pitting lower extremity edema. On follow up two months later the edema completely resolved. Clinicians should be aware of the presentation and management of insulin induced edema. In most of the cases in literature, insulin induced edema started after starting insulin in newly diagnosed Type 1 diabetes or uncontrolled Type 2 diabetes. The pathophysiology is unclear. There is some evidence that insulin deficiency causes a catabolic state and hyperglycemia increases tissue capillary permeability. Re-introduction of insulin causes free water retention and renal excretion of sodium. This along with increased capillary permeability can lead to insulin edema. Water retention caused by the effect of counter regulatory hormones can also play a role. Insulin edema needs to be differentiated from other causes of diffuse edema. Management is generally supportive including temporarily decreasing insulin doses, salt restriction and diuretics as needed. Patient reassurance is important as well to aid in adherence to the prescribed insulin regimen. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Insulin edema after initiation of hybrid closed-loop insulin pump therapy with continuous glucose monitoring: a case report

BackgroundInsulin edema is a rare complication which can present after initiation or intensification of insulin therapy in people with diabetes. Initiation of closed-loop hybrid insulin pump therapy can result in rapid improvement in glycemic control for people with diabetes. We present a case in which transition to a closed-loop hybrid insulin pump system, followed by significant improvement in glycemic control, led to development of insulin edema in a person with type 1 diabetes.Case presentationWe present a 51-year-old woman with type 1 diabetes of 16 years duration, on insulin pump therapy for more than 10 years, who presented for follow-up 7 weeks after transitioning to a hybrid closed-loop insulin pump system with continuous glucose monitoring (CGM). She complained of weight gain and bilateral lower extremity edema which had started two weeks after the change in pump modality. Laboratory studies and echocardiogram did not reveal any etiology of the acute edema. HbA1c was 3.3% lower than the previous measurement 15 weeks earlier, and there was a significant increase in the daily total insulin dose. With exclusion of other causes of acute edema, the patient was diagnosed with insulin edema and started on hydrochlorothiazide. On follow up, her lower extremity edema significantly improved although her weight did not return to baseline.ConclusionTo our knowledge, this is the first case of insulin edema reported in a person with type 1 diabetes using CGM and a hybrid closed-loop insulin pump system. The increase in total daily insulin dose, rapid improvement of glycemic control, and lack of hypoglycemic episodes were important factors to consider in evaluation of this case. Use of hybrid closed-loop systems can help achieve rapid improvement in glycemic control in people with diabetes. This case suggests that consideration should be given to adjusting initial blood glucose targets when starting these remarkable new technologies in people with baseline poor glycemic control.

Unexplained Anasarca in Type 1 Diabetes Mellitus

Background: Undiagnosed Type 1 diabetes mellitus (T1DM) often presents as diabetic ketoacidosis (DKA). We report a child with newly diagnosed T1DM who developed anasarca and persistent diarrhea following resolution of DKA and was referred to us for the same. Clinical Description: We reviewed the clinical history, examination, and investigations that had been undertaken. Our clinical evaluation was in concurrence with the referring hospital-anasarca with probable partially treated spontaneous bacterial peritonitis (SBP). However, the cause of the subacute anasarca and persistent diarrhea was unclear. The child was empirically started on broad-spectrum antibiotics for the SBP, a high-protein diet to build up the protein, and continued the same subcutaneous insulin, on which he was euglycemic. After ruling out usual causes, i.e., renal, hepatic, and cardiac, we reviewed the possibility of celiac disease, tuberculosis, insulin edema, and hypothyroidism. Management: When he did not improve despite a good appetite, adherence to management, and all tests were inconclusive, we reviewed the etiopathogenesis. Untreated T1DM had led to chronic negative catabolism that had precipitated severe hypoproteinemia. A vicious cycle had set in which hypoalbuminemia was leading to bowel wall edema, resulting in protein malabsorption, perpetuation of diarrhea, and further hypoproteinemia. Our assumption proved to be correct when a single dose of parenteral albumin broke the cycle, and the child improved drastically with the resolution of diarrhea within 24 h and the edema in a few days. Conclusions: This case highlights the implications of severe catabolism in a patient with untreated diabetes and how this may be a self-perpetuating condition.

Insulin edema in an adolescent girl with newly diagnosed Type 1 diabetes mellitus

Background: Insulin edema is a rare complication that can occur following either initiation or intensification of insulin treatment in Type 1 diabetes mellitus (DM). It is an under reported condition. Awareness of this complication among physicians is important for early identification of this condition, and prompt initiation of treatment. Clinical Description: We present an 11-year-old girl with 2-month history of weight loss and 1-month history of polyuria and polydipsia who presented to us in moderate diabetic ketoacidosis. She developed anasarca and pulmonary edema 3 days after starting insulin. She also developed transaminitis a serum serum glutamic-oxaloacetic transaminase of 81 U/L and serum glutamic pyruvic transaminase of 83 U/L. A diagnosis of insulin edema was established after ruling out other causes like severe anemia, renal, cardiac and allergic causes. We also present a brief review of seven similar cases that we identified on a literature search. Management and Outcome: This included salt and fluid restriction along with diuretics. Edema resoled after 4 days of treatment, while transaminitis took 7 days to normalize. Conclusion: This case report highlights the importance of early recognition of the rare complication of insulin edema which can avoid unnecessary anxiety on the part of both treating physicians and parents of patients with Type 1 DM.

Factitious Hypoglycemia and Insulin Edema due to Surreptitious Insulin Use in a Patient with Type 1 Diabetes Mellitus

Background: Insulin edema is an uncommon but well-known complication of insulin therapy, mostly appreciated in patients soon after commencement or intensification of insulin therapy. Objectives: To report a case insulin edema in Type 1 Diabetes due to surreptitious excess self-insulin use triggered by poverty driven psychosocial stressors. Case Presentation: A 14-year girl with T1DM since age 8 years, with chronic poor glycemic control (Insulin 48 units/day basal-bolus; HbA1c 12.5%, despite 100% free medical care, medicines, diagnostics and counselling), presented with multiple episodes of unexplained hypoglycemia with documented low blood sugar readings (30-60 mg/dl) and “apparently” grossly decreased recent insulin requirements (4 units/day) This was associated with rapid weight gain, swelling of her face, limbs and abdomen as well as shortness of breath. Work up for acute/sub-acute renal, hepatic, cardiac, pulmonary or infectious disorders was negative. Fluid and salt restriction, close clinical monitoring and compassionate counselling resulted in prompt amelioration of hypoglycemia, resolution of edema, weight gain and shortness of breath. In-depth clinical assessment suggested the diagnosis of surreptitious excess insulin use, triggered by psychosocial and economic stressors, leading to factitious hypoglycemia and consequent insulin edema causing fluid retention and dyspnea. Discussion: To our knowledge, this is the first documented case of insulin edema in a patient previously diagnosed with T1DM due to the surreptitious use of insulin by the patient resulting from psychosocial stressors, similar to those in other published encounters. Conclusion: Insulin edema resulted from transient surreptitious (nontherapeutic) excess self-insulin use, triggered by psychosocial stressors.

A Rare Complication of Insulin Therapy in a Child with Newly Diagnosed Type 1 Diabetes: Insulin Edema

A Rare Complication of Insulin Therapy in a Child with Newly Diagnosed Type 1 Diabetes: Insulin Edema

Type 1 Diabetes Mellitus Patient Presented with Insulin Edema only after Intensive Lifestyle Changes: A Case Report and Brief Review of the Literature

Insulin edema is considered a rare type of generalized edema that occurs after initiation or intensification of insulin treatment in patients with diabetes mellitus (DM). In this case report, we present a clinically significant edema that developed following a dramatic improvement in glycemic control after intensive improvement in lifestyle in a 13-year-old girl, with type 1 DM confirmed by positive anti-glutamic acid decarboxylase (anti-GAD) antibodies. She had poor glycemic control during 2 years of insulin therapy, and following lifestyle improvements (with no changes to her medications types or doses), she developed generalized body edema, and facial puffiness that resolved spontaneously, without any intervention.

Insulin Edema Associated With Newly Diagnosed Type 1 Diabetes and High Glycated Hemoglobin: A Case and Review of the Pediatric Literature

Insulin edema is a rare and poorly understood complication of insulin therapy. It has been associated with the initiation of insulin in patients with newly diagnosed diabetes or the intensification of insulin therapy in those with poor glycemic control. This condition is rarely reported in pediatric patients. We describe a case of insulin edema in a 14-year-old boy with potential risk factors of highly elevated glycated hemoglobin at diagnosis and history of unilateral renal atrophy. We also present a discussion of the pathophysiology of this condition and a review of the pediatric literature.

Insulin-induced edema in a pediatric patient - clinical case

Introduction: Insulin edema is a rare condition associated with improved glycemic control shortly after diabetes diagnosis or following a period of insulin omission. Clinical findings range from mild edema to severe heart failure and pleural effusion. Diagnosis is clinical and other edema causes should be excluded. Since it is a self-limited condition, there is no need to modify insulin regimen. In more severe cases, diuretic therapy may be required.Clinical case: A 14-year-old female was brought to the Emergency Department due to weight gain and leg swelling with three days of evolution. She had been diagnosed with type 1 diabetes at the age of nine. The girl had poor metabolic control which led to multiple hospitalizations, the last one occurring the week before with a glycated hemoglobin higher than 15%. In physical examination, lower limb edema and a 7-kg weight gain were noted. No jugular vein distension, hepatomegaly, or other forms of edema were found. The girl was hemodynamically stable, with diuresis within the normal range. Analytical study consisting of hemogram, ionogram (sodium and potassium), and renal and hepatic function was normal. Urine analysis revealed glycosuria and chest x-ray showed no abnormalities. The diagnosis of insulin-induced edema was established and water and saline restriction recommended, with total symptom resolution three weeks later.Conclusion: Despite rare, clinicians should be aware of this condition, as most cases do not require modifying the insulin regimen.

Anasarca in Newly Diagnosed Type 1 Diabetes: Review of the Pathophysiology of Insulin Edema

Insulin edema is a rare complication of insulin therapy that can occur after the initiation of insulin. Various timelines to the initiation of insulin have been reported after insulin therapy. Here, we report the occurrence of generalized edema in a 40-year-old woman early after the initiation of insulin. Significant differentials were excluded and resolution achieved after two weeks with diuretics. We reviewed the current literature and the possible mechanisms behind this phenomenon.

Lower limb oedema in diabetes

Lower limb oedema in diabetes

Œdème insulinique au cours d’une glycogénose hépatique

IntroductionHepatic glycogenosis is a rare syndrome, which includes poorly controlled diabetes mellitus, hepatomegaly, delayed puberty, and growth delay. Insulin edema is sometimes associated. Case reportAn 18-year-old woman presented with diffuse edema, hepatomegaly, amenorrhea, uncontrolled diabetes, and elevated transaminases and cholestasis. Hepatic ultrasonography and abdominal computed tomographic scan confirmed the hepatomegaly. The liver biopsy showed a massive glycogenosis and the diagnosis of hepatic glycogenosis was confirmed. Too large doses of insulin were responsible of diffuse edema. Diabetes equilibration and diminution of insulin intakes allow correction of this disorder. ConclusionExcess of insulin can lead to excessive hepatic glycogen storage by activation of glycogenosis enzymes. Biological manifestations consist on elevated liver enzymes and hyperlactatemia. There is a link between administration of high dose of insulin and edema. Hepatic glycogenosis should be suspected when diabetes is uncontrolled and be considered as a differential diagnosis of steatosis. It may be associated and revealed by insulin edema directly related to excessive insulin intakes.

Insulin Edema in Newly Diagnosed Type 1 Diabetes Patient

Insulin Edema in Newly Diagnosed Type 1 Diabetes Patient

Insulin Edema in Type 1 Diabetes Mellitus: Report of a Case and Brief Review of the Literature.

Insulin Edema in Type 1 Diabetes Mellitus: Report of a Case and Brief Review of the Literature.

An Unusual Cause of Generalized Insulin Edema and Truncal Neuropathy

Insulin edema and acute neuropathy are rare side effects of insulin initiation or rapid improvement in glycemic control. Both conditions occurring simultaneously are very rare and there are no previous data on truncal neuropathy as a dominant feature. A 35-year-old lady, who presented with an infected, necrotic fourth finger and was admitted for debridement and antibiotics, developed diabetic ketoacidosis. Past medical history included latent autoimmune disease of adults. She was non-compliant with medication and had experienced significant weight loss (37 kg; body mass index (BMI) 15.1 kg/m 2 ). She was glutamic acid decarboxylase antibody positive, with poor glycemic control (HbA1c 133 mmol/mol (14.3%)). She was treated with intravenous and then subcutaneous insulin. From day 3, she developed significant pitting edema to her umbilicus. She was treated with furosemide 40 mg once daily and fluid restriction. Other causes of edema were excluded. Peak weight gain was 5 kg and edema resolved 2 weeks later. She also developed a painful sensory neuropathy over dermatomes T12-L2 on day 5, which persisted for several months before resolution. Magnetic resonance imaging was normal and nerve conduction studies showed generalized diabetic sensorimotor neuropathy. This is the first report of edema and truncal neuropathy developing secondary to insulin initiation and a rapid improvement in glycemic control. Our case was particularly susceptible due to poor glycemic control, low bodyweight, hepatic dysfunction and low serum albumin. This case highlights the importance of being aware of the rare complications of insulin therapy, particularly in susceptible patients. J Med Cases. 2015;6(12):563-565 doi: http://dx.doi.org/10.14740/jmc2345w

Insulin oedema in newly diagnosed type 1 diabetes patient: a case report

Insulin oedema in newly diagnosed type 1 diabetes patient: a case report