Diabetes/Prediabetes/Hypoglycemia
Jovana Vidovic, MD
Resident Physician
New York Presbyterian Brooklyn Methodist
Brooklyn, New York, United States
As bone marrow transplants (BMT) become a more common therapy option for patients with leukemia and lymphoma, there are an increasing number of long-term survivors. However, new long-term complications are arising including graft vs host disease (GvHD), hypertension (HTN), diabetes mellitus (DM) and metabolic syndrome. Cutaneous GvHD (cGvhD) can present as sclerotic or non-sclerotic. We present a middle-aged male who was treated with allogeneic BMT for acute lymphocytic leukemia (ALL) whose course was complicated by sclerotic cGvHD and increasing insulin resistance.
Case(s) Description :
A 59-year-old male with a past medical history of type 2 DM, primary hyperparathyroidism, obesity, heart failure with preserved ejection fraction, HTN, Hyperlipidemia, chronic kidney disease, and ALL status post allogeneic BMT complicated by cGvHD presented to our outpatient endocrinology clinic for uncontrolled diabetes. The patient was first diagnosed with DM four years prior to his ALL diagnosis, which was 30 years prior to his current presentation. At the time of presentation his HbA1c was 10.2% and c peptide was 1.5 ng/ml. Physical exam was notable for diffusely thickened and sclerotic skin. The patient was on an insulin pump using Humulin R U-500 with a total daily basal insulin dose of 72 units (72 x 5 = 360 units of U-100 insulin) and boluses of 15-50 units of U-500 insulin three times daily with meals (equivalent to 225-750 units of U-100 insulin), resulting in a total daily requirement of up to 1,110 units. The patient was previously on metformin extended release 500 mg nightly and empagliflozin 10 mg daily, which had recently been held due to worsening renal function. Over the past three years since he began following at our endocrinology clinic his HbA1c has improved to 8.0%.
Discussion :
As BMT becomes a more frequently used treatment for ALL it is important to acknowledge the potential side effects. Survivors of allogeneic BMT are more likely to be diagnosed with diabetes once adjusted for age, sex, race, and body mass index. Previous studies revealed long-term survivors of ALL with BMT had reduced β-cell reserve and smaller pancreatic volume. Post-transplant DM (PTDM) complicated by cGvHD is an under-recognized complication with an unclear pathophysiologic basis. Further studies are needed to elucidate the mechanisms driving severe insulin resistance in these patients.