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Management of a Complex Case of Treatment Induced Neuropathy of Diabetes in a Primigravida Female with Poorly Controlled Type II Diabetes Mellitus and HELLP Syndrome.
Abstract Number: RF4AD-292
Abstract Type: Case Report Case Series
Introduction: Treatment induced neuropathy of diabetes (TIND), previously known as insulin neuritis, is characterized by peripheral or generalized allodynia and paresthesias starting within 2-4 weeks after initiation of antihyperglycemic treatment [1,2]. The neuropathic pain is often described as sharp or stabbing . The pathophysiology is attributed to rapid changes in the glycemic level after diabetes treatment initiation . TIND may be refractory to usual treatments for diabetic neuropathy, including antidepressants, anticonvulsants, and SSRIs, and can be especially hard to treat in pregnant and breastfeeding women.
Case Report: The patient is a 37 year old primigravida female with poorly controlled type II diabetes who was found to have a HbA1c of 12.7% at time of pregnancy diagnosis for which she started insulin. Three months after initiation of insulin, patient presented to the ED with sharp, stabbing upper back and shoulder pain radiating to the chest. Computed tomography was performed to rule out pulmonary embolus. Her symptoms remained refractory to lidocaine patches, wellbutrin, gabapentin, duloxetine, and biofreeze. The patient had as many as 20 encounters during pregnancy attributed to pain. During a hospital admission for hypokalemia at 24 weeks EGA, her HbA1c was 5.6% and she was diagnosed with TIND by neurology. Antihyperglycemic regimen was reduced to metformin, but pain crises continued with patient requesting narcotic medication. At 30 weeks EGA, patient developed HELLP syndrome requiring cesarean delivery. The postpartum course was further complicated by persistent TIND, hyperalgesic response to incision wounds, episodes of muscle twitching, and hypnagogic hallucinations for which psychiatry diagnosed an adjustment disorder. Three months postpartum, patient reported resolution of her generalized pain, but continued to have peripheral neuropathy.
Discussion: This case demonstrates the unique challenge of acute pain management in an already high risk pregnancy with HELLP syndrome during labor and delivery. We successfully managed this patient with conservative diabetic management, preterm delivery, and multimodal pain therapy with gabapentin, duloxetine, ibuprofen, lidocaine patch, and low dose opioids. This case further illustrates the need for more awareness among healthcare providers regarding TIND to avoid confusion with psychiatric disorders and malingering, such as drug seeking behavior.
1. Gibbons CH. Treatment induced neuropathy of diabetes. Curr Diab Rep, Oct 2017, 17(12):127.
2. Hwang YT, Davies G. ‘Insulin neuritis’ to ‘treatment-induced neuropathy of diabetes’: new name, same mystery. Practical Neurology. 2016, 16(1):53
3. Dabby R et al. Acute painful neuropathy induced by rapid correction of serum glucose levels in diabetic patients. Biomed Pharmacother. 2009;63:707.