Diabetes mellitus with multimedia prototypes

Acute complications

• Hyperglycemic crisis: undiagnosed or insufficiently treated diabetes mellitus may result in severe hyperglycemia, potentially culminating in a crisis
  • Hyperglycemic hyperosmolar state (HHS)
  • Diabetic ketoacidosis (DKA)
• Life-threatening hypoglycemia: secondary to inappropriate insulin therapy

Long-term complications ^[1]

Macrovascular complications of diabetes (atherosclerosis)

• Prevalence: more common in patients with type 2 diabetes
• Risk factors: : The major determinants are metabolic risk factors, which include obesity, dyslipidemia, and arterial hypertension. Hyperglycemia may be less related to the development of macrovascular disease.
• Manifestations
  • Coronary heart disease (most common cause of death)
  • Cerebrovascular disease
  • Peripheral artery disease (possible loss of limb)
  • Monckeberg arteriosclerosis
  • Gangrene

Microvascular complications of diabetes

• Onset: typically arises 5–10 years after onset of disease
• Pathophysiology: chronic hyperglycemia → nonenzymatic glycation of proteins and lipids → thickening of the basal membrane with progressive function impairment and tissue damage
• Manifestations
  • Diabetic nephropathy
  • Diabetic retinopathy, glaucoma
  • Diabetic neuropathy, including diabetic gastroparesis
  • Diabetic foot

Gastroparesis can complicate the management of diabetes by causing poor absorption of oral antidiabetic drugs and difficulties with timing insulin doses due to delayed food absorption. ^[2]

Strict glycemic control is crucial in preventing microvascular disease.

Necrobiosis lipoidica ^[3]

• Definition: inflammatory granulomatous disorder of the skin; characterized by collagen degeneration and lipid accumulation in the surface of the skin.
• Epidemiology
  • > 60% association with DM
  • ♀ >> ♂
• Clinical features
  • Rash: circumscribed, erythematous plaques with atrophic centers and irregular margins
  • Common sites: pretibial region
  • Usually asymptomatic
  • Ulcerations with subsequent scarring may occur.
• Histopathology: necrobiotic palisading granuloma
  • Lymphohistiocytic infiltration with plasma cells, foam cells, and giant cells
  • Wall thickening and occlusion of small blood vessels
  • Destruction of collagen fibers in the entire corium
• Treatment: Corticosteroids may be effective (e.g., intralesional corticosteroid injections).

Other complications

• Mucormycosis (zygomycosis)
• Diabetic cardiomyopathy: a disorder of the myocardium seen in patients with diabetes ^[4]
  • Chronic hyperglycemia results in altered metabolism of glucose and fatty acids, microangiopathy with endothelial dysfunction, and autonomic neuropathy, which collectively results in cardiomyocyte hypertrophy, myocardial fibrosis, ventricular dilation, and ultimately in systolic and/or diastolic heart failure.
  • This disorder may or may not be accompanied by CVD and hypertension.
• Osmotic damage: occurs in tissues with high aldolase reductase activity and low/absent sorbitol dehydrogenase activity (e.g., eyes, peripheral nerves) → cataracts, neuropathy
• Diabetic fatty liver disease
• Hyporeninemic hypoaldosteronism ^[5]
  • Hypoaldosteronism that is caused by decreased renin activity
  • Most commonly caused by diabetic nephropathy or chronic interstitial nephritis
  • Patients present with features of hypoaldosteronism, i.e., hypotension, hyponatremia, and type 4 renal tubular acidosis.
• Limited joint mobility syndrome (formerly known as diabetic cheiroarthropathy) ^[6]
  • Manifested as stiffness of the small joints of the hand
  • Tight waxy skin, particularly on the dorsal surface of the fingers, is common.
  • Positive prayer sign: inability to approximate the palms due to flexion contractures of the PIP and MCP joints ^[7]
  • Positive tabletop test: inability to flatten the palm against the surface of a table due to the contractures in the metacarpophalangeal joints
• Sialadenosis
• Increased risk of infection

Insulin purging ^[8]

• Definition: attempting to lose weight by purposefully not injecting insulin after meals
• Population: young patients with type 1 diabetes with eating disorders use insulin purging as an alternative to fasting, vomiting, and other methods of weight loss
• Result: self-induced insulin deficiency → ↓ insulin-dependent glucose uptake in cells → ↓ anabolic effect of insulin → weight loss (no weight gain)
  • Poor glycemic control
  • Increased risk of hyperglycemic crises

We list the most important complications. The selection is not exhaustive.