Necrobiosis Lipoidica in Type 1 Diabetes Mellitus – Two Cases Reports

Presentation Number: SAT 638
Date of Presentation: April 1st, 2017

Cecilia Kauffman Rutenberg Feder*1, Delane Szapira Wajman2, Nilza Maria Scalissi3, Joao Eduardo Nunes Salles4, Luis Eduardo Calliari2, Monica de Aguiar Medeiros5 and Mariana Vieira Pereira6
1Irmandade Santa Casa de Misericordia de São Paulo, Sao Paulo, Brazil, 2Santa Casa de Misericordia de Sao Paulo, 3Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil, 4Endocrinology and Metabology Unit, Santa Casa de São Paulo, Sao Paulo, Brazil, 5University Santa Casa de Sao Paulo, 6Santa Casa de Misericordia de Sao paulo

Abstract

Introduction: Necrobiosis lipoidica (NL) is a granulomatous inflammatory skin disease frequently associated hyperglycemia. It is known that it occurs more frequently in women (3:1) and middle-aged patients. Some studies show that the prevalence of NL in patients with diabetes mellitus (DM) is around 0,3% to 1,6%. It is characterized by an asymptomatic skin lesion, localized typically in the pretibial area. There is not a specific treatment, but corticosteroids are the most commonly used drugs. Since it is a rare skin disease and strongly correlated with T1DM, our aim is to report two cases of NL. Case 1: A 20-years old female patient, with T1DM since she was 2 years old, presented with a bilateral pretibial red-yellowish lesion that had appeared 6 months before the consultation. She always had important glucose variability, and HbA1c fluctuated between 8.8 and 13.8%. Her initial insulin treatment was with NPH and Regular Insulin, in 2008 regular was changed to rapid insulin and in 2016 NPH was switched to glargine. She was also on metformin 2g/day, due to association with obesity (IMC 30,8Kg/m2) and signs of insulin resistance. No other autoimmune disease was found. She is also a smoker. Physical exam showed a slightly elevated, rounded red-yellowish pretibial lesion, with violaceous periphery. As it clinically suggested NL, a biopsy was indicated for diagnostic purposes. Histologic features confirmed Necrobiosis Lipoidica. Case 2: A 29-years old female patient, diagnosed with T1DM when she was 7 years old and hypothyroidism with 9 years old (Hashimoto thyroiditis), presented at the consultation with a pretibial lesion on the right leg characterized by a brownish macula with purple periphery. Her initial insulin treatment was with NPH and Regular insulin and 1 year ago turned to NPH and Lispro. She was diagnosed with retinopathy when she was 12 years old and 1 year later with nephropathy, showing her difficulties dealing with the disease. Her HbA1C always was high, between 10-12% but nowadays it had really improved (8,3%). She is taking enalapril, sinvastatin, fluoxetine, NPH, Lispro and Levothyroxine. She smokes since she was 24 years old and her BMI is 24 kg/m2. Physical exam showed pretibial lesion on the right leg characterized by a brownish macula with purple boarders. As it clinically suggested NL, a biopsy was indicated, and concluded the diagnose of Necrobiosis Lipoidica. Conclusion: Although it is not pathognomonic of DM, 65% of NL cases are associated to this condition. In addition studies demonstrate that 15% of the patients with NL will have diabetes in the future. The importance of these cases is to draw attention to a rare form of skin lesion associated with diabetes. Therefore, the prompt detection and diagnosis is important to define the correct etiology and treatment.

 

Nothing to Disclose: CKRF, DS, NMS, JENS, LEC, MDAM, MVP