An Unusual Cause of Generalized Insulin Edema and Truncal Neuropathy

Abstract

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.

Insulin Edema With Use of U-500 Regular Insulin in a Hybrid Closed-Loop Insulin Pump

“…In previous case reports, patients with insulin-induced edema were substantially malnourished or underweight [3,5,6]. Our patient, who had longstanding diabetes, was not insulin naive and had excessive body weight prior to the development of edema.…”

Insulin-Induced Edema in a Patient with Type 2 Diabetes Mellitus

“…It is proposed that the anti-natriuretic effect of insulin plays an important role in the mechanism of fluid retention through its significant influence on the transport of electrolytes in the kidney [ 14 ]. It appears that it increases tubular sodium retention in the kidney, and transient hyperaldosteronism coupled with hyperglycemia might enhance this effect, particularly in patients with uncontrolled diabetes [ 9 ]. This anti-natriuretic action of insulin as a salt-retaining hormone is now unambiguous.…”

“…However, ephedrine showed promising results in the treatment of insulin-induced edema. Despite being a vasoconstrictor and sympathomimetic agent, it can be superior to diuretic therapy in selected cases [ 9 ].…”

“…Edema, peripheral or generalized, is a rare complication of insulin therapy, which mostly occurs after initiating intensive insulin treatment in patients with newly diagnosed or poorly controlled diabetes [ 1 , 2 ]. Cases of this rare condition have continued to emerge even in recent years [ 3 – 9 ], despite vast improvements in the chemistry and manufacture of insulin molecules.…”

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

“…There are no criteria or risk stratification systems for the diagnosis of insulin edema, and it is diagnosed by the exclusion of other common causes of body edema. However, aged being from 20 to 40 years, poor control diabetes either by having frequent hypoglycemia or following DKA treatment, newly diagnosed diabetes with higher doses of insulin therapy, poor glucose control, and low body mass index have been suggested as risk factors for insulin edema [5] [6].…”