Louisiana Via Research Day Book 2026

Case Studies: Section 1

Case Studies: Section 1

Danny Lee, MD¹; Jenny Lee, BA²; Aymen Arain, OMS-II³; Julianna Gregory, RN, BS; Gaity Wahab, MS-3; Maryam Babar, OMS-II³; Cassie Cummings, MD¹ 1 Department of Internal Medicine, University of California Stanyan Hospital; 2 Rosalind Franklin University; 3 VCOM-Louisiana; 4 Florida State University; 5 Ross University School of Medicine 65 RECURRENT DIABETIC KETOACIDOSIS IN A YOUNG WOMAN WITH DIABULIMIA DESPITE COMPREHENSIVE OUTPATIENT SUPPORT

Lindsey Brierre, OMS-II 1 ; Emily Richard, MD 2 ; Joel Silverberg, MD 3 ; Everett Bonner, Jr., MD 4 ; Dr. Melissa Lipsmeyer, PhD 5 1 Mississippi College; 2 Dermatology, The Baton Rouge Clinic ; 3 Endocrinology, The Baton Rouge Clinic; 4 General Surgery and Surgical Breast Oncology, The Baton Rouge Clinic; 5 VCOM-Louisiana 66 SUBCUTANEOUS FAT NECROSIS AT CONTINUOUS SUBCUTANEOUS INSULIN INFUSION SITES FOLLOWING CESAREAN DELIVERY PRESSURE: A RARE CASE REPORT

Context: Diabulimia, the intentional omission or reduction of insulin in individuals with type 1 diabetes mellitus (T1DM) to induce weight loss, is an underrecognized and dangerous condition associated with significant morbidity and mortality. While outpatient multidisciplinary management involving endocrinology, psychiatry, and therapy is commonly pursued, some cases may exceed the capacity of outpatient care, highlighting the need to reassess treatment thresholds and care models. Report of Case: Ms. C is a 24-year-old woman with a history of T1DM, diabulimia, depression, anxiety, PTSD, and bipolar disorder who presented repeatedly over several years with episodes of diabetic ketoacidosis (DKA) secondary to intentional insulin omission. Despite consistent follow-up with endocrinology, psychiatry, and therapy, as well as prior admission to an eating disorder program, she continued to manipulate insulin dosing in the context of disordered eating behaviors. Her clinical course was marked by frequent hospitalizations, multiple ICU admissions for severe DKA with electrolyte disturbances, and alternating periods of improved glycemic control

followed by relapse associated with body image concerns and psychosocial stressors. Despite high insight into the consequences of insulin restriction and regular engagement with outpatient care, repeated life-threatening events persisted. Conclusions: This case illustrates the severity and chronicity of diabulimia in certain patients and demonstrates the limitations of even robust outpatient multidisciplinary care frameworks. It underscores the need for specialized inpatient treatment programs capable of addressing both complex eating disorders and the intensive medical management required for insulin dependent diabetes. The case further highlights the importance of defining clear thresholds for escalation to inpatient care in individuals with coexisting T1DM and eating disorders.

Background: Continuous subcutaneous insulin infusion (CSII) is widely used in patients with type 1 diabetes mellitus and is generally well tolerated. Common infusion-site complications include infection, lipohypertrophy, and localized irritation; however, painful subcutaneous fat necrosis is rarely reported. Subcutaneous fat necrosis is an uncommon inflammatory condition associated with localized trauma, pressure, ischemia, or injection-related injury. This case describes a delayed, bilateral presentation of fat necrosis at prior insulin pump sites following cesarean delivery in a patient with long-standing type 1 diabetes, emphasizing the importance of recognizing pressure-related complications of CSII placement in peripartum patients. A 33-year-old G2P1 female with a history of juvenile-onset type 1 diabetes mellitus presented for an elective cesarean delivery of her second pregnancy in January 2023. The pregnancy was complicated by preeclampsia, and the delivery course was further complicated by postpartum hemorrhage. Prior to surgery, CSII devices were placed bilaterally in the gluteal region as contingency access sites in the event of device failure during the procedure. Approximately six months postpartum,

in July 2023, the patient presented to her endocrinologist with progressively painful, firm nodules at the previous insulin pump insertion sites on both buttocks. She denied fever or systemic symptoms. Initial tissue culture demonstrated rare growth of coagulase-negative Staphylococcus species. Targeted ultrasound of the left gluteal soft tissue revealed a complex ovoid cystic collection within the subcutaneous fat with overlying skin thickening, measuring 2.3 × 0.6 × 2.1 cm, with similar findings noted on the right. Both lesions were aspirated, yielding small volumes of serosanguinous fluid. Persistent symptoms prompted bilateral core biopsies in August 2023, which demonstrated fibroadipose tissue with reactive fibrosis, fat necrosis, mixed inflammatory infiltrate, and scattered foreign body giant cells, without evidence of malignancy. Additional punch biopsies were performed in September 2023 due to ongoing pain and drainage. Despite partial symptomatic improvement, the lesions persisted, and surgical consultation ultimately recommended complete excision. Definitive surgical excision was performed in December 2023, with complete healing and resolution of symptoms by July 2024. A focused literature review was

conducted using PubMed, Google Scholar, case reports, reviews, and observational studies. Subcutaneous fat necrosis is a benign condition most often associated with trauma, pressure, ischemia, or injection-related injury. While fat necrosis has been reported following insulin injections, involvement of CSII sites, particularly in the perioperative or postpartum setting, remains rare. In this case, prolonged surgical positioning during cesarean delivery, combined with localized tissue trauma from CSII placement and underlying diabetic microvascular disease, likely contributed to bilateral fat necrosis. Compared with prior reports, this case is notable for delayed onset, bilateral involvement, and a prolonged course requiring multiple diagnostic procedures prior to definitive management. This case underscores the importance of considering subcutaneous fat necrosis in patients with persistent soft tissue lesions at insulin pump sites and highlights the potential need for early surgical intervention when conservative management fails.

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2026 Research Recognition Day