Relapsing insulin-induced lipoatrophy, cured by prolonged low-dose oral prednisone: a case report

Abstract

Introduction: Circumscript, progressing lipoatrophy at the insulin injection sites is an unexplained, however rare condition in diabetes mellitus.

Case presentation: We report a case of severe localised lipoatrophy developing during insulin pump-treatment (continuous subcutaneous insulin infusion) with the insulin analogue lispro (Humalog®) in a woman with type-1 diabetes mellitus. After 11 months of progressing lipoatrophy at two spots on the abdomen, low-dose prednisone (5-10 mg) p.o. was given at breakfast for 8 months, whereby the atrophic lesions centripetally re-filled with subcutaneous fat tissue (confirmed by MRI) despite ongoing use of insulin lispro. However, 4 weeks after cessation of prednisone, lipoatrophy relapsed, but resolved after another 2 months of low-dose prednisone. No further relapse was noted during 12 months of follow-up on insulin-pump therapy with Humalog®.

Conclusion: Consistent with an assumed inflammatory nature of the condition, low-dose oral prednisone appeared to have cured the lipoatrophic reaction in our patient. Our observation suggests a temporary intolerance of the subcutaneous fat tissue to insulin lispro (Humalog®), triggered by an unknown endogenous mechanism.

Figure 1

Follow-up of lipoatrophic sites, before, during, and after prednisone therapy. Series of photographs showing lipoatrophic areas on both sides of the umbilicus (upper panel: left side, lower panel: right side). Photographs as of March 2009 and April 2009 were taken before prednisone therapy. In April 2009, a biopsy was taken from the right side, which healed uneventfully, see lower panel. Low-dose oral prednisone was administered from the last week of June 2009 until March 2010, and from May 2010 until June 2010. To be continued on Figure 2.

Figure 2

Follow-up of lipoatrophic sites, before, during, and after prednisone therapy pt. 2. Continuation from Figure 1. Low-dose oral prednisone was administered from the last week of June 2009 until March 2010, and from May 2010 until June 2010. The photographs as of July 2011 were taken 12 months after cessation of prednisone therapy.

Figure 3

MRI demonstrating re-grown subcutaneous fat tissue at sites of previous lipoatrophy. Axial T1-weighted MRI sequence (1.5 Tesla Magnet, body surface coil, slice thickness 3 mm) acquired through the abdomen, March 2010. Markers are placed over the healed lipoatrophic area (left side), and over the biopsy scar (right side), respectively. Signal intensity and subcutaneous tissue structure indicate re-grown subcutaneous fat tissue at the healed area (left side; high signal intensity, identical to that of periumbilical subcutaneous fat tissue), and fibrous tissue at the biopsy area, respectively (right side; signal intensity is only half of that of subcutaneous fat tissue).