Effects of Switching from Degludec to Glargine U300 in Patients with Insulin-Dependent Type 1 Diabetes: A Retrospective Study.

Background and Objectives: Degludec (Deg) and glargine U300 (Gla-300) are insulin analogs with longer and smoother pharmacodynamic action than glargine U100 (Gla-100), a long-acting insulin that has been widely used for many years in type 1 and type 2 diabetes. Both improve glycemic variability (GV) and the frequency of hypoglycemia, unlike Gla-100. However, it is unclear which insulin analog affects GV and hypoglycemia better in patients with insulin-dependent type 1 diabetes. We evaluated the effects of switching from Deg to Gla-300 on the day-to-day GV and the frequency of hypoglycemia in patients with insulin-dependent type 1 diabetes treated with Deg-containing basal-bolus insulin therapy (BBT). Materials and Methods: We conducted a retrospective study on 24 patients with insulin-dependent type 1 diabetes whose treatment was switched from Deg-containing BBT to Gla-300-containing BBT. We evaluated the day-to-day GV measured as the standard deviation of fasting blood glucose levels (SD-FBG) calculated by the self-monitoring of blood glucose records, the frequency of hypoglycemia (total, severe, and nocturnal), and blood glucose levels measured as fasting plasma glucose (FPG) levels and hemoglobin A1c (HbA1c). Results: The characteristics of the patients included in the analysis with high SD-FBG had frequent hypoglycemic events, despite the use of Deg-containing BBT. For this population, SD-FBG and the frequency of nocturnal hypoglycemia decreased after the switch from Deg to Gla-300. Despite the decrease in the frequency of nocturnal hypoglycemia, the FPG and HbA1c did not worsen by the switch. The change in the SD-FBG had a negative correlation with the SD-FBG at baseline and a positive correlation with serum albumin levels. Conclusions: Switching from Deg to Gla-300 improved the SD-FBG and decreased the frequency of nocturnal hypoglycemia in insulin-dependent type 1 diabetes treated with Deg-containing BBT, especially in cases with low serum albumin levels and a high GV.

Thyrotoxicosis Misdiagnosed as Long Covid by Telemedicine - A Cautionary Tale.

Introduction: Individuals who have had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may develop post-coronavirus disease conditions, also known as long COVID. The symptoms of long COVID are nonspecific, and there are similarities between the symptoms of long COVID and those of Graves' disease (GD). Therefore, it is important to rule out GD in patients suspected of having long COVID. Telemedicine is widely used to avoid the risk of SARS-CoV-2 infection. However, owing to the lack of in-person examinations, diagnostic errors can occur. Case description: A 27-year-old Japanese woman presented complaining of persistent fatigue, dyspnea, and low-grade fever, and after in-person examination was finally diagnosed with GD. She had been diagnosed with SARS-CoV-2 infection four months earlier and her symptoms had resolved within 5 days but then recurred. Subsequently, she had 3 telemedicine visits and had been diagnosed with long COVID. Discussion: With telemedicine there may be delayed diagnosis of GD in patients with a recent history of SARS-CoV-2 infection. Some symptoms and abnormalities cannot be confirmed in telemedicine visits performed using a simple mobile phone. Therefore it is important to know which findings obtained in telemedicine visits with a simple mobile phone are suggestive of GD. Low-grade fever and tachycardia are often observed in patients with GD, but rarely occur in patients with long COVID. Conclusion: Tachycardia and persistent low-grade fever after SARS-CoV-2 infection, which can be confirmed by telemedicine, can be clues for the diagnosis of GD. Therefore, in-person examination should be added if these symptoms are confirmed by telemedicine. LEARNING POINTS: The symptoms of Graves 'disease (GD) and long COVID may overlap.With telemedicine there may be delayed diagnosis of GD, in patients with recent history of severe acute respiratory syndrome mediated by coronavirus 2 (SARS-CoV-2) infections.In telemedicine visits, tachycardia and persistent low-grade fever could be clues for the diagnosis of GD after SARS-CoV-2 infections on telemedicine.

Fulminant type 1 diabetes developed after influenza split vaccination.

Summary: Fulminant type 1 diabetes (FT1D) is a subtype of diabetes characterized by rapid progression of ß-cell destruction, hyperglycemia, and diabetic ketoacidosis (DKA). The pathogenesis of this disease remains unclear. However, viral infections, HLA genes, and immune checkpoint inhibitor use were reportedly involved in this disease. A 51-year-old Japanese man with no chronic medical condition was admitted to our hospital with complaints of nausea and vomiting. Cough, sore throat, nasal discharge, and diarrhea were not noted. He had a medical history of at least two influenza infections. His vaccination history was notable for receiving an inactive split influenza vaccine 12 days prior to developing these symptoms. He was diagnosed with DKA associated with FT1D. His HLA class II genotypes were nonsusceptible to FT1D, and he had a negative history of immune checkpoint inhibitor use. The destruction of the pancreas by cytotoxic T cells is reported to be involved in FT1D. Inactive split influenza vaccines do not directly activate cytotoxic T cells. However, these could activate the redifferentiation of memory CD8-positive T cells into cytotoxic T cells and induce FT1D, as this patient had a history of influenza infections. Learning points: Influenza split vaccination could cause fulminant type 1 diabetes (FT1D). The mechanism of influenza split vaccine-induced FT1D might be through the redifferentiation of CD8-positive memory T cells into cytotoxic T cells.

Adrenal Hemorrhaging in a Patient with Severe Obstructive Sleep Apnea Syndrome with Elevated Plasma ACTH Levels.

Adrenal hemorrhaging (AH) is a rare condition characterized by bleeding into the suprarenal glands. A 62-year-old man with untreated obstructive sleep apnea syndrome (OSAS) was admitted to our hospital complaining of abdominal stiffness. He was diagnosed with left-sided AH and underwent adrenalectomy. Pre- and post-surgery, elevated plasma adrenocorticotropic hormone (ACTH) levels were observed. However, Cushing's syndrome and adrenal insufficiency were negative, and nasal continuous positive airway pressure (CPAP) normalized the plasma ACTH levels. Elevated ACTH levels are reportedly present in patients with OSAS. ACTH may be associated with the development of AH through the change in blood supply and other mechanisms.

Hiccups as the first presentation of secondary adrenal insufficiency associated with advanced cervical cancer.

Summary: Hiccups are a common symptom characterized by intermittent spasmodic contraction of the diaphragm. Most hiccups are transient, but some are refractory. Patients with intractable hiccups often have abnormalities of the diaphragm, medulla oblongata, and lesions affecting nerve fibers connecting them. Moreover, electrolyte abnormalities, including hyponatremia, are frequently observed in patients with intractable hiccups. Adrenal insufficiency (AI) is one of the causes of hyponatremia. However, hiccups are not commonly the first presentation. Herein, we describe a case of a 45-year-old woman complaining of refractory hiccups. The patient was initially diagnosed with hiccups associated with cervical cancer metastasis to the liver and peritoneum. The administration of chlorpromazine did not have a beneficial effect on her hiccup. Fasting hypoglycemia and hyponatremia were later found. Her serum cortisol level was low without an elevation of adrenocorticotropic hormone level. MRI of the pituitary gland showed metastatic lesion in the pituitary gland and stalk. Thus, the patient was diagnosed with secondary AI due to cervical cancer metastasis to the pituitary gland and stalk. Administration of hydrocortisone improved her hiccups with the normalization of serum sodium level. Therefore, differential diagnosis in advanced cancer patients with hiccups should include AI-induced hyponatremia. Learning points: Hiccups could be the first manifestation of adrenal insufficiency (AI). Hiccups in patients with AI are often mediated by hyponatremia. Hyponatremia is less frequent in secondary AI than in primary AI. However, hyponatremia can result from increased antidiuretic hormone due to loss of cortisol. The differential diagnosis should include AI-induced hyponatremia if hiccups occur in patients with advanced cancer, as metastasis to adrenal gland or pituitary gland could cause AI.

Fresh Cerebral Infarction-Like MRI Findings Mimicking Hyperosmolar Hyperglycemic Syndrome With Seizures.

Hyperosmolar hyperglycemic syndrome (HHS) is a severe diabetes-related condition. Patients with HHS can present with abnormal magnetic resonance imaging (MRI) findings similar to those of fresh cerebral infarction. Here, we present the case of a 95-year-old woman with HHS who was initially misdiagnosed with seizures due to fresh cerebral infarction of the pons. Her MRI revealed small abnormal lesions in bilateral pons which showed hyperintensity on T2-weighted imaging and diffusion-weighted imaging. Thus, the patient was initially diagnosed with seizures associated with fresh cerebral infarction of the pons. However, hyperglycemia and hyperosmolarity were later observed, and the patient was diagnosed with HHS. Intravenous insulin and saline infusions were administered, which led to improvements in laboratory findings and seizures. The MRI findings of the pons disappeared after the treatment of HHS. Cortical restricted diffusion is observed in about 60% of cases with HHS, even if no obstruction of the artery is detected. On the contrary, patients with HHS have an increased risk of stroke during the treatment of HHS. Therefore, it is crucial for clinicians to examine patients with neurological symptoms associated with HHS not only based on MRI findings but also on neurological examination over time. In conclusion, clinicians should be aware of fresh cerebral infarction-like MRI findings in patients with HHS.

Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome Worsen after the Administration of Dulaglutide.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is characterized by symmetrical polyarthritis and limb pitting edema. Although the detailed mechanisms of this syndrome have not been clearly understood, some agents including dipeptidyl peptidase-4 inhibitors have been reported to induce RS3PE syndrome. However, glucagon-like peptide-1 (GLP-1) analogues have not been reported to be associated with this syndrome. A 91-year-old woman was admitted to our hospital with complaints of severe polyarthritis and limb edema. She was diagnosed with RS3PE syndrome. Oral prednisolone improved her symptoms. However, her symptoms worsened after the administration of dulaglutide, with elevated serum inflammatory markers. Discontinuation of dulaglutide without additional treatment improved her symptoms and laboratory findings. This case might indicate the possibility of development and worsening of RS3PE syndrome caused after GLP-1 analogue.