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Ambawatte S, Wijewickrama P, Gunarathne K, Somasundaram N. Bruns Garland Syndrome as the first presentation of type 2 diabetes: two case reports and a practical approach to diagnosis. J Med Case Rep 2024; 18:99. [PMID: 38360756 PMCID: PMC10870480 DOI: 10.1186/s13256-023-04327-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/18/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Diabetes is a global health problem causing a significant burden on the healthcare systems both due to the disease itself and associated complications. Diabetic radiculoplexus neuropathies or Bruns-Garland syndrome constitutes a rare form of microvascular complications, more commonly affecting the lumbosacral plexus and, very rarely, the cervical plexus. We describe two Sri Lankan males who presented with diabetic lumbosacral radiculoplexus neuropathy and diabetic cervical radiculoplexus neuropathy as the initial manifestation of diabetes. CASE DESCRIPTION Case 1: a 49-year-old Sri Lankan hotel chef presented with subacute painful weakness and wasting of the left upper arm for 3 months and weight loss. Left upper limb proximal muscles were wasted with diminished power and reflexes. A nerve conduction study showed comparative amplitude reduction. An electromyogram revealed positive sharp waves, frequent fibrillations, and high amplitude polyphasic motor unit potentials with reduced recruitment in proximal muscles of left upper limb. Case-2: a 47-year-old Sri Lankan carpenter presented with subacute progressive asymmetrical painful weakness and wasting of bilateral thighs for 5 months and weight loss. Lower limb proximal muscles were wasted with reduced power and knee jerks. The nerve conduction study was normal. The electromyogram was similar to case 1 involving both quadratus femoris muscles, which was more prominent on the left side. The work up for an underlying etiology revealed only elevated fasting blood glucose and HbA1c, suggesting a new diagnosis of diabetes associated with neurological symptoms. Patient 1 was diagnosed with diabetic cervical radiculoplexus neuropathy and patient 2 with diabetic lumbosacral radiculoplexus neuropathy. Both showed significant improvement following optimization of glycemic control together with symptomatic treatment and physiotherapy. CONCLUSION Diagnosis of diabetic radiculoplexus neuropathy requires a comprehensive workup to rule out other sinister pathologies. This case report has a dual importance; it describes diabetic radiculoplexus neuropathy as the very first manifestation of two previously healthy people, giving rise to a new diagnosis of diabetes and, at the same time, reporting on diabetic cervical radiculoplexus neuropathy, which is extremely rare and has never been previously reported in Sri Lanka.
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Affiliation(s)
| | | | - Kamal Gunarathne
- Neuro-Electrophysiology Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Noel Somasundaram
- Diabetes & Endocrinology, Unit National Hospital of Sri Lanka, Colombo, Sri Lanka
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Wijewickrama P, Onyema M, Eid H, Phare N, Dick J, Moutzouris D, Lambie M, Vas P, Williams J, Karalliedde J. Standards of diabetes care and burden of hypoglycaemia in people with diabetes on peritoneal dialysis: Results from a real-world clinical audit. Perit Dial Int 2023:8968608231195492. [PMID: 37702352 DOI: 10.1177/08968608231195492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
There is limited data on the standards of diabetes care in people on peritoneal dialysis (PD). Our aim was to assess the standards of diabetes care and the burden of hypoglycaemia in people with diabetes on PD. We performed a retrospective study at three university hospitals from December 2021 to January 2022. Clinical data were extracted from electronic health records. Diabetes care of people on PD was compared against recommended standards for people with diabetes on haemodialysis (as there are no agreed standards for PD). The degree of hypoglycaemia awareness was assessed by validated questionnaires. A total of 65 adults (15 type 1, 49 type 2 and 1 monogenic-diabetes) with a mean age of 63 (range 29-88) years were evaluated. Of them, 92% had diabetes retinal screening with annual review. In contrast, in this high-risk group for foot disease, only 77% had annual foot reviews. The rates of diabetes specialist reviews were variable between hospitals at 63-94% and 10 (15%) had impaired hypoglycaemia awareness. Of the cohort, 32% had HbA1c within the acceptable range of 58-80 mmol/mol (7.5-8.5%), 21% had HbA1c below 58 mmol/mol (7.5%) and 21% (n = 14) reported at least one hypoglycaemic event per month. Our results indicate variation of care within and between different centres, and the need for improved diabetes care in people on PD. Further work is required to establish agreed standards/recommendations of diabetes care in this population. Our findings highlight the necessity of an integrated multidisciplinary approach to improve the standard of diabetes care for people on PD.
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Affiliation(s)
| | | | - Hatem Eid
- King's College Hospital London, UK
- Guy's & St Thomas' Hospital, London, UK
| | | | | | | | | | | | | | - Janaka Karalliedde
- King's College Hospital London, UK
- Guy's & St Thomas' Hospital, London, UK
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Mangelis A, Wijewickrama P, Nirmalakumaran A, Fountoulakis N, Vas P, Webster L, Mann S, Collins J, Hopkins D, Thomas S, Ayis S, Karalliedde J. People With Type 1 Diabetes of African Caribbean Ethnicity Are at Increased Risk of Developing Sight-Threatening Diabetic Retinopathy. Diabetes Care 2023; 46:1091-1097. [PMID: 37062044 PMCID: PMC10154654 DOI: 10.2337/dc22-2118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/27/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE There is limited information on the effect of ethnicity on the development of referable sight-threatening diabetic retinopathy (STDR) in people with type 1 diabetes. This study describes the risk factors for STDR in a diverse cohort of people with type 1 diabetes attending a regional diabetes eye screening service. RESEARCH DESIGN AND METHODS Clinical and digital retinal imaging data from 1,876 people with type 1 diabetes (50% women, 72.1% Caucasian, 17.3% African Caribbean, 2.9% Asian, and 7.6% other) with no retinopathy at baseline, attending surveillance eye screening were reviewed. Referable STDR was defined as the presence of any moderate to severe nonproliferative or preproliferative diabetic retinopathy or proliferative diabetic retinopathy or maculopathy in either eye as per U.K. National Diabetic Eye Screening criteria. Median follow-up was 6 years. RESULTS The median (interquartile range) age of the cohort was 29 (21, 41) years. Of the cohort of 1,876 people, 359 (19%) developed STDR. People who developed STDR had higher baseline HbA1c, raised systolic blood pressure (SBP), longer diabetes duration, and were more often of African Caribbean origin (24% vs. 15.6%; P < 0.05 for all). In multivariable Cox regression analyses, African Caribbean ethnicity (hazard ratio [HR] 1.39, 95% CI 1.09-1.78, P = 0.009), baseline SBP (HR 1.01, 95% CI 1.00-1.01, P = 0.033), and baseline HbA1c (HR 1.01, 95% CI 1.00-1.01, P = 0.0001) emerged as independent risk factors for STDR. CONCLUSIONS We observed that people with type 1 diabetes of African Caribbean ethnicity are at significantly greater risk of STDR. Further research is required to understand the mechanisms that explain this novel observation.
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Affiliation(s)
- Anastasios Mangelis
- School of Population Health & Environmental Sciences, King's College London, London, U.K
- Optima Partners, Edinburgh, U.K
| | - Piyumi Wijewickrama
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - Abbeyramei Nirmalakumaran
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - Nikolaos Fountoulakis
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - Prashanth Vas
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - Laura Webster
- South East London Diabetic Eye Screening Programme and St Thomas' Hospital, London, U.K
| | - Samantha Mann
- South East London Diabetic Eye Screening Programme and St Thomas' Hospital, London, U.K
| | - Julian Collins
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - David Hopkins
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - Stephen Thomas
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
| | - Salma Ayis
- School of Population Health & Environmental Sciences, King's College London, London, U.K
| | - Janaka Karalliedde
- King's Health Partners and School of Cardiovascular Medicine & Sciences, King's College London, London, U.K
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Frankel AH, Wahba M, Ashworth V, Bedi R, Berrington R, Buckley M, Chandrasekharan L, Doyle F, Duval D, Game F, Hamilton S, Hussain S, James J, Jebb H, Karalliedde J, Kong MF, Kuverji A, Lambie M, Main C, Price S, Wijewickrama P, Williams J, Dhatariya K, Chowdhury TA. Management of adults with diabetes on dialysis: Summary of recommendations of the Joint British Diabetes Societies guidelines 2022. Diabet Med 2023; 40:e15027. [PMID: 36524709 DOI: 10.1111/dme.15027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Diabetes is the commonest cause of end-stage kidney disease in many parts of the world, and many people on dialysis programmes live with diabetes. Such people are vulnerable to complications from their diabetes, and their care may be fragmented due to the many specialists involved. This updated guidance from the Joint British Diabetes Societies aims to review and update the 2016 guidance, with particular emphasis on glycaemic monitoring in the light of recent advances in this area. In addition, the guidance covers clinical issues related to the management of diabetes in people on peritoneal dialysis, along with acute complications such as hypoglycaemia and ketoacidosis, and chronic complications such as foot and eye disease.
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Affiliation(s)
| | - Mona Wahba
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, UK
| | - Vicky Ashworth
- School of Health Sciences, Institute of Clinical Sciences, University of Liverpool, Liverpool, UK
| | - Rachna Bedi
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | - Fiona Doyle
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, UK
| | | | - Frances Game
- University Hospitals of Derby and Burton NHS Foundation, Derby, UK
- University of Nottingham, Nottingham, UK
| | - Susie Hamilton
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - June James
- Leicester Diabetes Centre, Leicester, UK
| | - Hannah Jebb
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Apexa Kuverji
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Sara Price
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Tahseen A Chowdhury
- Department of Diabetes and Metabolism, The Royal London Hospital, London, UK
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Elhassan YS, Ronchi CL, Wijewickrama P, Baldeweg SE. Approach to the Patient With Adrenal Hemorrhage. J Clin Endocrinol Metab 2023; 108:995-1006. [PMID: 36404284 PMCID: PMC9999363 DOI: 10.1210/clinem/dgac672] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.
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Affiliation(s)
- Yasir S Elhassan
- Correspondence: Yasir Elhassan, MBBS, MRCP, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
- Division of Endocrinology and Diabetes, University Hospital University Würzburg, Würzburg 97080, Germany
| | - Piyumi Wijewickrama
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
| | - Stephanie E Baldeweg
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
- Centre for Obesity and Metabolism, Department of Experimental and Translational Medicine, Division of Medicine, University College London, London WC1E 6BT, UK
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Wijewickrama P, Williams J, Bain S, Dasgupta I, Chowdhury TA, Wahba M, Frankel AH, Lambie M, Karalliedde J. Narrative Review of glycaemic management in people with diabetes on peritoneal dialysis. Kidney Int Rep 2023; 8:700-714. [PMID: 37069983 PMCID: PMC10105084 DOI: 10.1016/j.ekir.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
There is an increasing number of people with diabetes on peritoneal dialysis (PD) worldwide. However, there is a lack of guidelines and clinical recommendations for managing glucose control in people with diabetes on PD. The aim of this review is to provide a summary of the relevant literature and highlight key clinical considerations with practical aspects in the management of diabetes in people undergoing PD. A formal systematic review was not conducted because of the lack of sufficient and suitable clinical studies. A literature search was performed using PubMed, MEDLINE, Central, Google Scholar and ClinicalTrials.gov., from 1980 through February 2022. The search was limited to publications in English. This narrative review and related guidance have been developed jointly by diabetologists and nephrologists, who reviewed all available current global evidence regarding the management of diabetes in people on PD.We focus on the importance of individualized care for people with diabetes on PD, the burden of hypoglycemia, glycemic variability in the context of PD and treatment choices for optimizing glucose control. In this review, we have summarized the clinical considerations to guide and inform clinicians providing care for people with diabetes on PD.
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Affiliation(s)
- Piyumi Wijewickrama
- Department of Diabetes and Endocrinology, University College London Hospital, London, UK
| | - Jennifer Williams
- Department of Renal Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Steve Bain
- Diabetes Research Unit, Swansea University, Swansea, UK
| | - Indranil Dasgupta
- Department of Renal Medicine, Heartlands Hospital Birmingham, Brimingham, UK
| | | | - Mona Wahba
- Department of Renal Medicine, St. Helier Hospital, Carshalton, UK
| | - Andrew H. Frankel
- Department of Renal Medicine, Imperial College Healthcare, London, UK
| | - Mark Lambie
- Department of Renal Medicine, Keele University, Keele, UK
| | - Janaka Karalliedde
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, UK
- Correspondence: Janaka Karalliedde, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London SE1 9NH, UK.
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Dematapitiya C, Perera C, Pathmanathan S, Subasinghe V, Anandagoda G, Dissanayaka V, Wijenayake U, Dissanayake P, Gamage K, Wijewickrama P, Sumanatilleke M. Parathyroid carcinoma during pregnancy: a novel pathogenic CDC73 mutation - a case report. BMC Endocr Disord 2022; 22:259. [PMID: 36284286 PMCID: PMC9594882 DOI: 10.1186/s12902-022-01169-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/05/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Parathyroid carcinoma is an uncommon cause of PTH-dependent hypercalcemia. Only a handful of cases have been reported of parathyroid carcinoma during pregnancy. CASE PRESENTATION Twenty-four - Year - old female presented with proximal myopathy was found to have hypercalcemia. Her serum corrected total calcium was - 15 mg/dl (8.5 - 10.3), serum phosphate - 2.3 mg/dl (2.5 - 4.5), intact PTH - 118 pg/ml (20 - 80), Vitamin D - 15 ng/ml and Urine Ca/Cr ratio - 2.1 (0.1 - 0.2). Her CECT-neck revealed a well-defined mass lesion posterior to the right lobe of the thyroid - 2.6 cm × 2.5 cm × 2.9 cm in size. She was started on vitamin D supplementation, and she underwent right lower focal parathyroidectomy. Her PTH levels normalized following surgery. Her histology revealed an atypical parathyroid adenoma. She was treated with calcium and vitamin D. Her follow up was uneventful. One year following initial surgery the patient became pregnant and at 16 weeks of POA, the patient presented with a rapidly enhancing neck mass for one week duration. Her biochemical investigations were suggestive of a recurrence of primary hyperparathyroidism. Her ultrasound scan of the neck revealed a well-defined discreate hypoechoic nodule, superior to the thyroid isthmus which was confirmed by a non-contrast MRI scan of the neck. She underwent an uncomplicated second trimester parathyroid tumour excision with normalization of post op PTH. Her histology revealed a parathyroid carcinoma with vascular and capsular invasion. Her genetic studies revealed a novel frameshift mutation of the CDC73 gene. She was treated with calcium and vitamin D supplementation and closely followed up with ionized calcium and PTH levels which were normal throughout the pregnancy. She had an uncomplicated caesarean section at a POA of 37 weeks. Currently she is twelve weeks post-partum, in remission of disease. CONCLUSION This case shows the importance of stringent follow up of atypical parathyroid adenoma patients, the benefit of second trimester surgery in management of hypercalcemia due to parathyroid carcinoma during pregnancy and the importance of identifying the novel CDC73 gene mutation.
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Affiliation(s)
| | - Chiara Perera
- Provincial Directorate of Health Services-Western Province, Colombo, Sri Lanka
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Ambawatte S, Weerathunga D, Dissanayake A, Somaratne S, Wijewickrama P. Cervical myeloradiculopathy with hypoglossal schwannoma mimicking amyotrophic lateral sclerosis. J Neurol Sci 2021. [DOI: 10.1016/j.jns.2021.119980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Aukorala I, Gunawardena N, Wijewickrama P, Atukorala K, Dahanayake B, Prasadinie H. FRI0188 Does Adding A Joint Count Improve the Usefulness of the Self Administered Inflammatory Arthritis Detection Tool in Detecting Early Rheumatoid Arthritis?: Table 1. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.2427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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