Painful fat necrosis resulting from insulin injections

Case - Leuprolide acetate-induced necrotic skin ulceration

Androgen deprivation therapy (ADT) has become a well-established modality in the management of locally advanced and metastatic prostate cancer.1 Leuprolide acetate, a synthetically derived gonadotropin-releasing hormone receptor (GnRHR) agonist, is commonly used for ADT in men.2 Despite proven effectiveness, the administration of GnRHR agonists is associated with common adverse reactions, such as impotence, hot flashes, and fatigue. Injection site reactions have also been documented, however, are infrequent, with the most common being localized pain.3,4 Here, we report a case of necrotic skin ulceration following multiple administrations of intramuscular leuprolide acetate.

Intra-orbital fat necrosis following transcaruncular orbitotomy mimicking a surgical site infection: A case report

Fat necrosis is a benign non-suppurative inflammation of adipose tissue most commonly occurring in breast, subcutaneous tissue or intraabdominal fat post trauma, surgery, radiation. Transcaruncularorbitotomy provides a safe, rapid, and cosmetically pleasing approach to the medial wall and orbital apex. Intraorbital fat necrosis as its complication has not been documented in literature. The authors report the case of an elderly lady who presented with localized pain, swelling following a transcaruncular orbitotomy for excision biopsy of an orbital vascular mass. The etiology, clinical presentation, intraoperative finding, imaging, and possible mechanisms contributing to the pathogenesis of postsurgical orbital fat necrosis has been suggested.

Subcutaneous, abdominal, and thoracic encapsulated fat necrosis in bowhead whales Balaena mysticetus from Alaska, USA

We describe a case series of encapsulated fat necrosis with subcutaneous, abdominal, and thoracic locations in 7 subsistence-harvested bowhead whales Balaena mysticetus. Masses had a variably-dense fibrous capsule surrounding necrotic adipocytes and calcium salts (saponification). One animal also had prior concussive injury, pleural fibrosis, and hepatic lipoma; the other animals had no significant findings. The described condition is uncommon in bowhead whales, with 7/575 (1.2%) observed from 1996 to 2015. The exact mechanisms of development of encapsulated fat necrosis in bowhead whales remain to be determined. Encapsulated fat necrosis has been reported in other baleen whales, humans, and cows. It is usually an incidental finding during post-mortem examination that needs to be differentiated from neoplastic and inflammatory lesions, as the latter may have public health implications. Assessment of further cases in bowhead whales and other baleen whales is warranted to better understand their pathogenesis.

Painful and Prolonged Muscle Cramps following Insulin Injections in a Patient with Type 2 Diabetes Mellitus: Revisiting the 1992 Duke Case

A 56-year-old middle-eastern male with a long-standing history of poorly controlled type 2 diabetes mellitus presented to us complaining of severely painful bilateral upper and lower extremity cramps occurring shortly after his rapid-acting insulin analog injection(s). The cramps had started 6 months ago and have been occurring intermittently in non-predictable episodes since then. He had otherwise never experienced any insulin-related adverse reaction(s) before. His cramps are very painful and debilitating, interfering with his daily activities and placing him in a state of constant fear/anxiety of re-experiencing them. This caused him to become non-adherent with his prescribed treatment and poorly compliant with his follow-up regimens. Thorough examination showed a diffuse loss of sensation over the lower limbs. This was subsequently confirmed with a combined electromyography-nerve conduction study which indicated extensive diabetic axonal polyneuropathy. By contrast, lower extremity segmental arterial pressures were negative for peripheral vasculo-occlusive disease, ruling out vascular insufficiency as a possible etiology of the cramps. We then measured the levels of serum electrolytes right-before and 30 min right-after injecting the patient with his insulin. Potassium dropped by about 16% from its initial level, compared to a drop of only around 4% for calcium and none (0%) for magnesium. Thus, we speculated this insulin-induced sharp drop in serum potassium levels as potentiating the patient's already existing advanced diabetic neuropathy, thereby leading to muscle cramping. However, attempting potassium supplementation for a brief period of time led to a rapid resolution of cramps when they occurred and an overall reduction in their frequency of recurrence. This tilted our diagnosis toward the insulin-induced acute drop in serum potassium levels as the most likely etiology underlying the patient's cramps. Such an observation has been made only once previously within the literature, back in 1992, at the Duke University Medical Center.

Massive Preperitoneal Hematoma after a Subcutaneous Injection

Preperitoneal hematomas are rare and can develop after surgery or trauma. A 74-year-old woman, receiving systemic anticoagulation, developed a massive preperitoneal hematoma after a subcutaneous injection of teriparatide using a 32-gauge, 4 mm needle. In this patient, there were two factors, the subcutaneous injection of teriparatide and systemic anticoagulation, associated with development of the hematoma. These two factors are especially significant, because they are widely used clinically. Although extremely rare, physicians must consider this potentially life-threatening complication after subcutaneous injections, especially in patients receiving anticoagulation.