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Diabetes is an umbrella term for a heterogeneous group of disorders that meet a single criterion for diagnosis: hyperglycemia. The etiologic classification of diabetes ranges from the most commonly encountered, type 2 diabetes, to the less common, including maturity-onset diabetes of the young, and everything in between. Although type 2 diabetes makes up a significant proportion of all patients with diabetes, classifying a particular patient’s disease accurately may be problematic; occasionally, even differentiating between type 1 and type 2 diabetes can present a challenge. Diabetes may come to clinical attention in conjunction with diseases of the exocrine pancreas, such as cystic fibrosis or hemochromatosis; in association with drugs or chemicals. such as glucocorticoids or phenytoin; other endocrinopathies, such as acromegaly or pheochromocytoma; uncommon forms of immune-mediated diabetes, such as Stiff-Person Syndrome; or genetic defects of insulin action, such as Leprechaunism.
Not uncommonly, the interpretation of hemoglobin A1C results can be affected by a number of factors, presenting a clinical dilemma to a practitioner, even though the diagnosis of diabetes itself may not often present a significant challenge.
Furthermore, the clinical presentations and complexities of diabetes management often present difficulties to the practicing clinician. The safe and effective use of insulin and other agents to lower glucose may require “thinking-outside-of-the-box” even for experienced clinicians. In addition, there is a rapidly growing array of medications available for treating diabetes. Additional considerations include the limitation to management by hypoglycemia, complications such as chronic kidney disease, and comorbidities such as obesity with concomitant worsening of insulin resistance. These are just a few of the factors that require a thoughtful approach to the management of individual patients. Patients with recurrent diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome, ketosis-prone diabetes, and severe insulin resistance continue to challenge our clinical abilities.
Diabetes in the hospital setting presents a unique set of intricacies, including renal failure and dialysis, need for enteral or parenteral nutrition, severe burns or trauma, organ transplantation, and surgery. Transitions within and between the hospital and outpatient settings often raise the risk of worsening clinical outcomes resulting from gaps and miscommunications in management.
Last, the use of technology has improved the lives of many people living with diabetes, but the practical and effective use of continuous subcutaneous insulin infusions (insulin pumps) and continuous glucose monitors requires significant training, education, and ability to troubleshoot and sometimes to generate creative solutions to manage diabetes optimally in an individual patient.
One of the best ways to learn about these numerous complex issues related to diabetes diagnosis, classification, and management, is by pooling together the expertise of clinicians taking care of patients with diabetes, and by exploring these topics through case presentations and discussions. The aim of this casebook, Diabetes Case Studies: Real Problems, Practical Solutions, is to do exactly that. This casebook includes contributions from many leading diabetologists from around the world who take care of patients with diabetes and, through deliberate practice, have compiled their thoughts and insights from their experience and inquiry into the specific topics discussed. We have tried to maintain the individual “voices” of the contributing authors as much as possible. We felt this was important to preserve the integrity of their contributions while upholding a high standard for each case presentation and discussion.
This book is divided into nine sections detailed as follows:
Cases 1–23: Diagnostic Dilemmas and Problems with Classification
Cases 24–27: HbA1c Dilemmas
Cases 28–36: More Insulin Is Not Always the Solution: Cases of Severe Insulin Resistance
Cases 37–52: Unusual Forms and Presentations of Diabetes
Cases 53–64: Diabetes in the Hospital Setting
Cases 65–78: Diabetes Management Pearls
Cases 79–93: The Limiting Factor: Issues in Hypoglycemia
Cases 94–100: Neuropathy in Diabetes
Cases 101–103: Diabetes in Pregnancy and Reproductive Issues
We hope the reader with a specific clinical question in mind will use this list of topics or the index to go straight to the cases that will be most likely to address his or her clinical question. If the reader has a few spare minutes and would like to learn something surprising or new, flipping to any page and perusing a few cases may open a world of complex and intriguing cases with clinical reasoning outlined and discussed by “master clinicians” from many parts of the world. If the reader has more time and does not have a specific clinical question, he or she might consider taking the time to browse through this book, and even read a few sections, to gain insight into the art of clinical deduction from the leading diabetologists who submitted their challenging cases to this anthology. We hope that the reader will find this to be a useful collection of clinical cases and gain as much from reading and using it as we have from assembling and editing it.
Finally, for additional information, the reader is referred to the American Diabetes Association Standards of Medical Care in Diabetes, which are updated yearly and provide a comprehensive resource for many diabetes-related questions.