Limited Joint Mobility in Type 1 Diabetes: Diabetic Cheiroarthropathy, a Neglected Entity.

Musculoskeletal disorders are common in type 1 and type 2 diabetes mellitus. Among them, diabetic cheiroarthropathy (DCA), more commonly seen in type 1 diabetes, is a late complication that often causes physical and emotional disturbance. DCA, characterized by movement restrictions in the small joints of hands, is usually a clinical diagnosis and bears significance owing to the functional hand disabilities that it causes and its association with various microvascular complications, most importantly retinopathy. A 24-year-old male patient, with type 1 diabetes of 20 years duration, presented to us with difficulties in performing fine motor tasks such as buttoning his shirt and with positive "Namaste" sign and "Table Top" sign. He had reduced sensation on monofilament testing, decreased vibration perception threshold, and a nerve conduction study suggested distal sensory demyelinating and axonal polyneuropathy. He had a restrictive pattern on pulmonary function tests, normal lung parenchyma on high-resolution computed tomography of his thorax, proliferative diabetic retinopathy, proteinuria, vitamin D deficiency, and subclinical hypothyroidism. He was followed closely with tight glycemic control and physiotherapy. In rural setups, DCA can act as a mirror to screen for macrovascular and microvascular complications if not already done routinely or previously. Management includes physiotherapy, glycemic control, patient education, and regular follow-up, with surgical procedures being only the last option.

Mitochondrial Dysfunction and Imeglimin: A New Ray of Hope for the Treatment of Type-2 Diabetes Mellitus.

Diabetes is a rapidly growing health challenge and epidemic in many developing countries, including India. India, being the diabetes capital of the world, has the dubious dual distinction of being the leading nations for both undernutrition and overnutrition. Diabetes prevalence has increased in both rural and urban areas, affected the younger population and increased the risk of complications and economic burden. These alarming statistics ring an alarm bell to achieve glycemic targets in the affected population in order to decrease diabetes-related morbidity and mortality. In the recent years, diabetes pathophysiology has been extended from an ominous triad through octet and dirty dozen etc. There is a new scope to target multiple pathways at the molecular level to achieve a better glycemic target and further prevent micro- and macrovascular complications. Mitochondrial dysfunction has a pivotal role in both ß-cell failure and insulin resistance. Hence, targeting this molecular pathway may help with both insulin secretion and peripheral tissue sensitization to insulin. Imeglimin is the latest addition to our anti-diabetic armamentarium. As imeglimin targets, this root cause of defective energy metabolism and insulin resistance makes it a new add-on therapy in different diabetic regimes to achieve the proper glycemic targets. Its good tolerability and efficacy profiles in recent studies shows a new ray of hope in the journey to curtail diabetes-related morbidity.

Pituitary Stalk Duplication: A Radiological Surprise in a Child With Short Stature.

Objective: Pituitary stalk abnormalities are one of the causes of hypopituitarism. Isolated pituitary stalk duplication with a single pituitary gland is extremely rare with only a few cases reported to date. The present case has a different clinical picture as compared to the cases that were previously reported in the literature. Case Report: A 2 years 6-month-old male child, a product of nonconsanguineous marriage, presented with short stature, micropenis with unilateral undescended testis, and delayed motor milestones. His bone age was delayed by 6 months. On further evaluation, he was found to be euthyroid, with stimulated growth hormone (GH) and stimulated gonadotropin levels were suboptimal, whereas the cortisol and the prolactin were normal. Magnetic resonance imaging of the pituitary revealed pituitary stalk duplication with a single pituitary gland of normal dimensions and fused tuber cinereum and mammillary body. Discussion: To our knowledge, only 7 cases with isolated pituitary stalk duplication were reported. The presenting complaint could be primarily of hypopituitarism like short stature or a neurologic complaint or ocular abnormality. The pituitary hormone deficiencies are variable with GH deficiency being the most common as seen in our case. Other associated features could be the morning glory disc anomaly, moyamoya disease, pituitary adenoma or hypoplasia, split hypothalamus, and sellar dermoid. Conclusion: Pituitary stalk duplication is a developmental disorder that is diagnosed only by imaging. Patients should be evaluated for hypopituitarism, particularly the GH and gonadotrophins deficiency, and also screened for associated neurologic and ocular abnormalities.

An Intriguing Case of Gynecomastia in an Elderly Male as the Initial Presentation of Graves' Disease: A Case Report.

Gynecomastia is the proliferation of fibroglandular tissue in the male breast due to an altered hormonal milieu between the inhibitory effect of androgens and the stimulatory effect of estrogens on the breast tissue causing feminization of the male breast. Physiological causes are more common along with a few pathological conditions leading to gynecomastia in the male population. Of these varied etiologies, thyrotoxicosis is one of the notable causes, though it is very rare in the elderly population. Gynecomastia as the initial presentation of Graves' disease that too in an elderly age group is very rare with very few cases reported in the literature. Here, we present a case of a 62-year-old male presenting with gynecomastia, who after a detailed evaluation, was diagnosed to have Graves' disease.

Addressing the Inertia: A Holistic Approach to Diabetic Foot Evaluation.

Diabetic foot is a well-known complication with considerable morbidity and mortality related to the diabetic population. Neuropathy, deformity, infection and ischemia are important contributors to the pathogenesis of diabetic foot ulcers. A multidisciplinary team approach by physicians, nursing staff, diabetic educators and the caregiver as well as close monitoring of feet by the patient himself can prevent foot-related complications. Proper foot care, foot hygiene, annual foot examination and the correct choice of footwear are the main elements in preventing foot problems like deformity, ulceration and amputations. Physicians play a key role in the early detection and prevention of foot problems. Foot evaluation is the most neglected part of physical examination in diabetic patients. This inertia is evident in both physicians and patients. Emphasis on visual inspection and physical foot examination at every visit may address the morbidity and mortality due to diabetic neuropathy and vasculopathy. This article will highlight extensively history taking and foot examination in the diabetic foot clinic. Optimal glycemic control, simple foot care practices, knowledge and appropriate footwear use play an important role to reduce the disease burden.