Microvascular and Macrovascular Complications of Diabetes Mellitus - Clinical Cases

Question 1

A 47-year-old man presents to his GP with erectile dysfunction. He is obese with a BMI of 33 kg/m² and blood pressure is 148/99 mmHg. On examination his GP notes darkened areas of skin in his axilla and behind his neck. He has two pale stretch marks on his abdomen. A random capillary blood glucose is 25mmol/L.

What is your differential diagnosis?

Answer 1

• T2DM (Acanthosis nigricans)
• Cushing’s syndrome (centripetal obesity / stretch marks)
• Hypogonadism (primary / secondary)

Question 2

A 47-year-old man presents to his GP with erectile dysfunction. He is obese with a BMI of 33 kg/m² and blood pressure is 148/99 mmHg. On examination his GP notes darkened areas of skin in his axilla and behind his neck. He has two pale stretch marks on his abdomen. A random capillary blood glucose is 25mmol/L.

What questions would you like to ask him next?

Answer 2

T2DM:
* Osmotic symptoms
* Blurred vision
* Fatigue

Cushing’s:
* Check appearance

Hypogonadism:
* Muscle deterioration
* Changes in shaving frequency
* Libido

Question 3

A 47-year-old man presents to his GP with erectile dysfunction. He is obese with a BMI of 33 kg/m² and blood pressure is 148/99 mmHg. On examination his GP notes darkened areas of skin in his axilla and behind his neck. He has two pale stretch marks on his abdomen. A random capillary blood glucose is 25mmol/L.

He has felt tired for some time and has noticed ~3kg of weight loss in the past 6 months and has significant thirst. The erectile dysfunction started a year ago and coincided with starting a new stressful job. He has a normal libido.

What investigations would you request to confirm your diagnosis and to help manage this patient?

Answer 3

T1DM/T2DM
* HbA1c (>48mmol/mol)
* Fasting glucose test (>7mmol/mol)
* Oral glucose tolerance test
* Random glucose test (>11.1mmol/mol)
* Albumin:creatinine ratio (microalbuminuria)
* Urine dipstick proteinuria

Morning testosterone for exclusion & LH/FSH for exclusion

Dexamethosone 48h test for cushing’s disease

Question 4

A 47-year-old man presents to his GP with erectile dysfunction. He is obese with a BMI of 33 kg/m² and blood pressure is 148/99 mmHg. On examination his GP notes darkened areas of skin in his axilla and behind his neck. He has two pale stretch marks on his abdomen. A random capillary blood glucose is 25mmol/L.

He has felt tired for some time and has noticed ~3kg of weight loss in the past 6 months and has significant thirst. The erectile dysfunction started a year ago and coincided with starting a new stressful job. He has a normal libido.

You obtain the patient’s blood results:
* HbA1c: 75 mmol/mol (20-41)
* Total cholesterol: 6.7 mmol/L (< 4)
* Triglycerides: 3.2 mmol/L (< 1.7)
* HDL: 0.7 mmol/L (> 1.2)
* LDL: 5.2 mmol/L (< 2)
* Creatinine: 98 umol/L (55-110)
* eGFR: > 90 ml/min/1.73m2 (>89)
* Urine albumin: creatinine 6 mg/mmol (< 2.5)
* Testosterone: 21 nmol/L (10-30)
* LH: 7 u/L (2-12)
* FSH: 6 u/L( 1.7-8)

Work through these investigations and describe what they show.

Answer 4

Suggestive of T1DM:
* Dislipidaemia (High cholesterol, triglycerides, LDL and low HDL -> low HDL indicates insulin resistance T1DM)
* High HbA1c
* Microalbuminuria

Question 5

A 47-year-old man presents to his GP with erectile dysfunction. He is obese with a BMI of 33 kg/m² and blood pressure is 148/99 mmHg. On examination his GP notes darkened areas of skin in his axilla and behind his neck. He has two pale stretch marks on his abdomen. A random capillary blood glucose is 25mmol/L.

He has felt tired for some time and has noticed ~3kg of weight loss in the past 6 months and has significant thirst. The erectile dysfunction started a year ago and coincided with starting a new stressful job. He has a normal libido.

You obtain the patient’s blood results:
* HbA1c: 75 mmol/mol (20-41)
* Total cholesterol: 6.7 mmol/L (< 4)
* Triglycerides: 3.2 mmol/L (< 1.7)
* HDL: 0.7 mmol/L (> 1.2)
* LDL: 5.2 mmol/L (< 2)
* Creatinine: 98 umol/L (55-110)
* eGFR: > 90 ml/min/1.73m2 (>89)
* Urine albumin: creatinine 6 mg/mmol (< 2.5)
* Testosterone: 21 nmol/L (10-30)
* LH: 7 u/L (2-12)
* FSH: 6 u/L( 1.7-8)

What are the principles of management in this case?

Answer 5

• Statins e.g. storvastatin (cheap and suitable)
• Metformin to improve effectiveness of insulin
• GLP-1 to lose weight
• Lifestyle advice with encouragement to lose weight, stop smoking, provide support
• Consider ACEi / ARB for hypertension
• Screen for neuropathy, nephropathy (ACR) and retinopathy (retinal screening scan)