Extent of lipohypertrophy in diabetic patients-Sometimes much more than meets the eye.

Lipohypertrophies frequently occur during insulin therapy. They alter insulin absorption, causing higher insulin requirements (and costs), fluctuating blood glucose and episodes of unpredictable hypoglycemia. Screening is mandatory, as well as assessment of their actual size. Counseling recommending regular changes of the injection sites ("rotating") is important to prevent LH.

INTRODUCTION

Lipohypertrophies (LH) occur in about 30% of patients under insulin therapy. A case with a surprising discrepancy between visual and actual extension of LH is reported, stressing the importance of screening for LH, and of size assessment to counteract problems like higher insulin requirements, fluctuating blood glucose and unpredictable hypoglycemia.

REPORT

An 84‐year‐old patient suffers from Type 2 diabetes for 25 years and is insulin‐dependent since 2003. Her blood glucose reports show considerable glucose fluctuations and an Hba1c of 8.2% (66 mmol/mol). Clinical examination revealed a rather inconspicuous protrusion (diameter 8 cm) of adipose tissue in the lower abdomen with multiple small puncture sites (Figure 1) compatible with LH. Because of weight loss (BMI 17.3 kg/m2), a computed tomography of the abdomen was performed. Contrastingly to the visible findings, a region compatible with LH of almost 18 cm in the transverse extent was identified (Figure 2).

Figure 1

Photograph of the patient's abdomen. The clinical examination revealed a rather small area around the navel with an inconspicuous protrusion of adipose tissue and multiple small puncture sites and scars

Figure 2

Axial CT scan image of patient's abdomen shows an area compatible with lipohypertrophy measuring approximately 18 cm in transverse diameter in the subcutaneous plane (see arrow)

Insulin therapy may cause LH due to lipogenic action and/or injection‐related tissue trauma with repeated administration in the same site.1 The prevalence of LH is reported at 37%.2 Injection into them is less painful. A problem is the loss of insulin effectiveness leading to higher insulin requirement (and costs) with fluctuating blood glucose concentrations and occasional episodes of unpredictable hypoglycemia. Counseling is important in LH prevention by educating patients about rotating the injection sites. Our patient was advised to do so and reduce the insulin dose by 10%. Three months later, her glycemic control had improved with an Hba1c of 7.3 (56 mmol/mol).

CONFLICT OF INTEREST

There are no conflicts of interest.

AUTHOR CONTRIBUTION

IAH drafted the article and has accountability for all aspects of the work.

ETHICAL APPROVAL

The patient gave written consent to report her case and the imaging.