Endocrine Abstracts

Introduction: Diabetic autonomic neuropathy (DAN) and CAN as one of its most common manifestations are serious complication of type 1 and type 2 diabetes mellitus leading to a significant increase in morbidity and mortality. Case presentationA 51-year old male, diagnosed with T2DM for 25 years, complicated by stage III diabetic polyneuropathy, proliferative retinopathy and several amputations on both feet, treated with Metformin (2g/day), Glargine (26 IU/day) and Aspart (21 IU/day), was admitted in our center for: neuropathic ulceration on the plantar surface of the 4th metatarsal head, hyperglycemia on self-monitoring, dry mouth, nocturnal enuresis (3 times/night), blurred vision and deep muscle cramps in the calves with insidious onset, lasting for 15-20 minutes and alleviated by Cilostazol administration. One year prior to current admission, he was diagnosed with Monckeberg sclerosis. On admission: altered general status, BP = 120/80 mmHg, Pulse=88b/min, symptomatic orthostatic hypotension, rhythmic cardiac sounds with stage III holosystolic murmur on the entire cardiac area, diminished peripheral pulses, multiple ecchymosis after insulin injection in the right lumbar region, bilateral plantar hyperkeratosis, interdigital maceration at the level of the 3rd and 4th space of the left foot. Lab exams revealed: inflammatory syndrome, iron deficiency anemia, hypocalcaemia and poor glycemic control (A<ce:inf>1</ce:inf>c=10.19%). The foot surgeon removed the affected soft tissue including the 4th metatarsal joint of the left foot. Under antibiotic therapy with Clindamycin (i.v) and Ciprofloxacin, α-lipoic acid, benfotiamine, aspirin, atorvastatin, cilostazol and iron substitution, the clinical evolution was slowly favorable. The plague culture was negative, possible in the context of prior Amoxicillin Clavulanate administration before hospital admission. Given his clinical presentation, a Cardiosys evaluation was performed, which confirmed the CAN diagnosis. In order to decrease the number of the symptomatic orthostatic episodes, 0.1 mg/day of Fludrocortisone was initiated under 24 h BP monitoring. The therapeutic education with emphasis on carbs ingestion, blood glucose self-monitoring and foot care was resumed. Conclusions This case illustrates typically the negative impact of peripheral and clinical CAN association on the quality of life (QoL). Unfortunately, the poor prognosis in this case relies mostly in the lack of adherence to the medical therapy and foot care.