Virginia Research Day 2025

Medical Resident Research Case Reports

19 Identifying and Managing Brittle Diabetes Mellitus Type I & II

Petros Sofroniou, MD; and Benjamin Lipham, DO Corresponding author: petros.sofroniou@lpnt.net

Sovah Health – Danville, Danville, Virginia

showing glucose at 78. Medication discontinued on discharge: Insulin Lantus, 24 units subcutaneously once every evening. The patient had been on Lantus and Aspart for 40 years. Hb A1c: 6.1 on 8/30, with the previous reading being 7.1 five months ago when she saw her endocrinologist. AM fasting point-of-care (POC) glucose was 210 today. Hb A1c was 6.1 on 08/30/24. Glucose POC was 249 in the clinic, while it ranged from 54 to a high of 500 this week. The plan is to achieve regular blood glucose monitoring by identifying patterns and preventing extreme highs and lows with a continuous glucose monitoring device throughout the day and making appropriate adjustments. Context: Brittle diabetes, also known as labile diabetes, is characterized by extreme fluctuations in blood glucose levels, leading to rapid and unpredictable changes that results in episodes of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). This instability makes it challenging to manage and can result from various factors, including hormonal changes, illness, dietary factors, insulin administration, or genetics.

Case Report: A 63-year-old female is evaluated in the ER due to multiple seizures prior to arrival, including a grand mal seizure, secondary to severe hypoglycemia. She follows up with the clinic upon discharge for recurrent hypoglycemia episodes, accompanied by dizziness and weakness. Medical History: GERD, chronic pain, chronic obstructive pulmonary disease, hypothyroidism, obstructive sleep apnea (OSA), hyperlipidemia, insulin-dependent diabetes mellitus (IDDM) complicated by peripheral neuropathy, and lupus. Social History: The patient uses a walker to ambulate and has smoked 67 cigarettes a day for over 40 years. Pertinent Review of Systems: Positive for: blurry vision, nausea/vomiting, diarrhea, wheezing, numbness/tingling, night sweats, low-grade fevers, chest pain on deep inspiration, and abdominal pain. Pertinent Physical Exam: Vital signs: BP 111/50, P 72, R 22, O2 sat 95% on room air. The patient is alert and oriented x4. Cranial nerves appear grossly intact. No focal motor or sensory deficits noted.

Pertinent Labs: White blood cell count 17.75, hemoglobin 11.9, potassium 3.0, ALT 12, UDS: cocaine positive. Pertinent Imaging: CT head without contrast showed no acute intracranial findings and mild chronic small-vessel ischemic disease. Diagnosis: Acute seizures secondary to severe hypoglycemia with a history of brittle insulin dependent diabetes mellitus type 2. Treatment: Upon ED arrival, EMS noted blood glucose levels to be 35 and administered 75 mL of D10W, which improved her blood sugar to 83. The patient had no recollection of events at home; her last memory was "eating to boil eggs" prior to the seizures. She reported struggling to get her insulin pump to work and had a poor appetite for 4-5 months. After an elevated blood glucose level, she was treated with regular insulin. The patient is currently on a moderate-dose sliding scale, and long-acting insulin has been discontinued. A hypoglycemia episode of 55 occurred a day prior to her residency clinic follow-up, during which she had to sit down due to dizziness, which resolved with a recheck

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2025 Research Recognition Day