Krishnan Swaminathan

Diabetes and Coronary Artery Disease in South Asians

South Asians originate from the Indian sub-continent and represent roughly one fifth of the world’s population. This ethnic group contributes to the highest proportion of coronary artery disease (CAD) burden, mainly attributed to the high prevalence of diabetes. However, other established and emerging risk factors are overrepresented in this population at a younger age. Further large scale research is needed to identify various genetic and environmental mechanisms underlying the increased diabetes and vascular risk in the South Asian population. Effective clinical strategies to reduce the risk of diabetes and CAD in the South Asian population are the need of the hour.

Not all hyperglycaemia is the same: an interesting case of secondary diabetes

Case report A 58-year-old woman with no significant past medical history, presented to her general practitioner with a 4-week history of lethargy, polyuria and glycosuria. Random glucose of 24.9 mmol/L confirmed the diagnosis of diabetes and in view of marked symptoms, an urgent referral to the clinic was organised. Clinical examination revealed a blood pressure of 227/128 mmHg, ‘plethoric face’ and a ‘Cushingoid appearance’ (figure 1). Routine biochemistry revealed serum potassium of 2.8 mmol/L (normal range 3.5–5 mmol/L), venous bicarbonate of 40 mmol/L (normal range 22–26 mmol/L) and grossly deranged liver function tests. An urgent in-patient admission was arranged in view of the above abnormalities. A random serum cortisol and paired ACTH levels were grossly elevated at 4,047 nmol/L (normal range 110–770) and 366 mu/L (normal range 2–20) respectively. Chest X-ray revealed a right pleural effusion. Chest CT revealed a large right hilar tumour (figure 2) measuring 5 cm diameter with a moderately large right pleural effusion. Abdominal imaging showed multiple liver metastases. Bronchial wall biopsy revealed features consistent with a small cell carcinoma of the lung. The final diagnosis was an ‘ectopic ACTH secreting small cell lung cancer’ presenting with new onset diabetes, hypertension, hypokalaemic alkalosis and Cushing’s syndrome. Subcutaneous insulin was commenced. Chemotherapy was not considered due to her general health. Metyrapone was started in an effort to reduce cortisol secretion but, unfortunately, deterioration was rapid and the patient died within 12 days of admission. Discussion We present an unusual case of ectopic ACTH secreting small cell lung carcinoma presenting initially with classical symptoms of diabetes, elevated random glucose, severe hypertension associated with hypokalemic alkalosis and features consistent with Cushing’s syndrome. Morphological changes of Cushing’s syndrome in such patients with highly aggressive cancer is extremely unusual as the hypercortisolism is acute and patients do not survive long enough for such changes to occur. Not all hyperglycaemia is the same: an interesting case of secondary diabetes

Solving the mystery: the ‘renal cysts and diabetes syndrome’

Diabetologists and non-specialist physicians have traditionally focused on treatment rather than diagnosis in the management of diabetes. The diagnosis of type 1 or type 2 diabetes in a busy admissions unit or a diabetes clinic is usually based on biochemical diagnostic criteria, age at onset, body mass index and the presence or absence of ketoacidosis. More challenging for the clinician is to utilise clinical skills and knowledge to detect monogenic diabetes, which has important consequences in terms of prognosis, treatment and family screening. We report an interesting case of monogenic diabetes, which solved the mystery behind a puzzling sequence of events that was a great source of confusion for the physician and concern for the patient.

Refractory hypoglycaemia in diabetes: a quinolone link

Quinolones are commonly used medications due to their broad spectrum of action and high oral bioavailability. However, clinicians should be aware of potential toxicities including hypoglycaemia and...

Diabetes and nephropathy is not always equal to diabetic nephropathy

In a busy diabetes clinic, it is always easy for the diabetologist to equate nephropathy and diabetes to “diabetic nephropathy”. Certain clinical clues should arouse suspicion of non-diabetic renal disease as this may have important implications in patient management. We report a case of multiple myeloma in a patient with diabetes presenting as “diabetic nephropathy”.

Pancreatic diabetes: an Indian perspective

Tropical calcific pancreatitis (TCP) and fibrocalculous pancreatic diabetes (FCPD) are unique forms of non-alcoholic pancreatitis and diabetes found almost exclusively in the tropics. Such patients can be erroneously labelled as having type 1 diabetes. A diagnosis of FCPD has potential implications in treatment, prediction of disease progression and complications. There are several characteristic features including young age of onset, progressive disease, non-ketotic diabetes, pancreatic calculi on imaging and a high risk of pancreatic cancer. Hyperglycaemia is usually severe and requires insulin, although ketoacidosis is a rare occurrence. Long term follow-up is necessary as microvascular complications have been reported. Macrovascular complications are less common due to a multitude of factors. The aetiology of TCP/FCPD is not clear but potential mechanisms include malnutrition, cyanogen toxicity, genetic factors, oxidant stress and micronutrient deficiency.

Recurrent cranial neuropathy in diabetes

Case report A 59-year-old man presented to our department with sudden onset of right-sided ptosis (figure 1) and diplopia, preceded by pain behind the right orbit. This patient had a left sixth nerve palsy a year ago, which had resolved spontaneously. His past history was notable for type 2 diabetes of 15 years duration. On examination, the visual acuity, colour vision and visual fields were normal. Both pupils reacted equally to light. Retinal examination showed features consistent with non-proliferative diabetic retinopathy. There was ptosis of the right eye (figure 1). On lifting the eyelid, abduction was observed in the natural position, with pupillary sparing (figure 2), consistent with a diagnosis of third nerve palsy. The results from examination of other cranial nerves, pyramidal tracts, sensory and cerebellar systems were normal. Glycaemic control was satisfactory on a combination of insulin and metformin with an admission HbA1C of 7.2%. Blood investigations including full blood count, renal and liver functions, lipid profile, serum electrolytes, erythrocyte sedimentation rate, ANA, viral markers and cerebrospinal fluid analysis were within normal limits. A brain MRI did not reveal any structural lesions, especially around the cavernous sinuses or posterior orbits. A clinical diagnosis of recurrent cranial neuropathy secondary to diabetes was considered and the patient made a complete recovery within 12 weeks of this presentation.

Unusual cause of leg pain: Diabetic pyomyositis

© SAGE Publications 2008 Los Angeles, London, New Delhi and Singapore 10.1177/1474651408094535 195 Introduction Patients with diabetes are predisposed to a range of different and unusual infections. It is important to have a high index of suspicion in such patients as the clinical presentation is usually vague and a delay in diagnosis can lead to significant morbidity and mortality. We present an interesting case of diabetic pyomyositis in a patient who presented with a history of painful leg.

Socioeconomic status, cardiovascular risk factors and the incidence of microvascular and macrovascular disease in type 1 diabetes

This study was undertaken to explore the associations between socioeconomic deprivation, prevalent cardiovascular risk factors and the development of microvascular and macrovascular complications in a cohort of subjects with type 1 diabetes mellitus in Scotland.We identified 2,314 people with type 1 diabetes from clinic records in six Scottish regions from 1989 to 1996. Postcode sectors were used to determine the Carstairs Index as a proxy for socioeconomic status. Clinic records and linkage to Scottish morbidity records allowed the association of socioeconomic status with the development of microvascular and macrovascular disease and the prevalence of cardiovascular risk factors to be evaluated.There was no overall association between prevalence of disease and socioeconomic status. There was a significant univariate relationship between smoking and deprivation (trend test p<0.0 D 0001; 47% of the most deprived were current smokers compared to 25% of the least deprived). Multivariate analysis showed that ...