Endocrine Abstracts

Case report: A previously well 16 year old female presented with a one day history of being unwell with agitation and confusion on the background of a three month history of polydipsia and polyuria. Initial biochemistry was in keeping with severe diabetic ketoacidosis (DKA): pH-6.75, HC03- 2.6 mmol/l, blood glucose- 21 mmol/l and ketones >4 mmol/l. Hypokalaemia of 3.3 mmol/l. She was admitted to ICU given the severity of DKA, biochemical disturbance and altered mental state. HbA1c was 157mmol/mol (16.5% DCCT) at diagnosis. Eight weeks after diagnosis, her HbA1c had improved to 62mmol/mol (7.8% DCCT). At this time she presented with acute onset burning pain in both feet, worse at night and unresponsive to simple analgesia. On discussion with the adult diabetic team a diagnosis of treatment-induced neuropathy in diabetes (TIND) was made and treatment with duloxetine and naproxen was initiated. Her symptoms resolved in three months.

Discussion: TIND is an acute, painful neuropathy that develops after rapid improvements in glycaemic control in individuals with longstanding hyperglycaemia. TIND is distinct from diabetic neuropathy due to its acute onset and often reversible nature. Neuropathic symptoms include pain, burning or allodynia. It can also be associated with autonomic dysfunction and microvascular complications. A decrease in HbA1c (glycosylated haemoglobin) of more than 2% points in 3 months, in individuals with chronic hyperglycaemia, leads to increased risk of TIND. Other risk factors include a high baseline HbA1c, female gender and weight loss. The current standard of care remains supportive.

Conclusion: TIND is an iatrogenic complication due to rapid improvements in glycaemic control in patients with diabetes. Symptoms of TIND are seen in up to 10% of adult patients with diabetic neuropathy. The prevalence of TIND in the paediatric population is unclear as literature is based solely on case reports [3]. Increased awareness and recognition of TIND in the paediatric population is required. Prospective mechanistic and therapeutic studies are needed to identify the pathophysiology and treatment of TIND.