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Introduction
A small proportion of type I diabetics are difficult to control and are called labile or brittle diabetics. One whose blood glucose repeatedly fluctuate between high and low levels are brittle diabetics, or it is defined as patients whose life is constantly, disrupted by episodes of hypo or hyperglycemia whatever be the cause.(1)
It can develop at any age in both men and women but it is the problem posed by young patient usually females. Some paediatricians claim that all children with diabetes are brittle. Its true prevalence is 1 to 2%.
We are reporting a case of NIDDM well controlled on oral hypoglycemic agents who use to go in for diabetic koto acidosis (DKA) during menstrual period only.
Case Report
A 45 year premenstrual female was admitted on 3rd July 1996 in M.Y. Hospital with history of NIDDM for last four years, well controlled on oral hypoglycemic agents and was without any complication of diabetes. For the last three months during premenstrual period she has pain in abdomen, anorexia, profuse vomiting and after that she had menorrahagia.
Her general examination was normal except for a depressed apathetic look and mild pallor. Pulse was 80/min., BP = 120/80 mm Hg. Her systemic examination revealed rnild epigastric tenderness. There was no organomegaly.
On investigation - urine sugar was 4+ and large ketones were found. Blood glucose was 800 mgm%. Other investigation were Hb=llgm%, T&D = 9000/cumm. Blood urea = 24 mgm%. Serum creatinine 0.9 mgm%. Serum T4 = 8ng/dl, Free T4- 1.4ng/dl, and USG abdomen was normal. Thus there was no obvious cause for her going in for DKA. There was no clinical or biochemical evidence of hyperthyroidism. There was no occult or evident infection including pulmonary tuberculosis.
She was started on hourly Insulin six units with frequent blood glucose monitoring and DKA was controlled in one day. She received total 60 units Insulin in 24 Hr. She was then switched on to human
Actrapid 8 units S/C BD and was discharged. She was taking regular Insulin. She was admitted 3 weeks later during menses with DKA. This time she required 120 units/day insulin to control her DKA and was controlled in three days time. She was discharged and was put on human Actrapid, 14 Units before lunch and 12 units before dinner.
Her third admission was after one month from 2nd admission during menstrual period with similar complaints and was found to be in DKA, again controlled on insulin in three days' time. Fourth time she was admitted in DKA in menstrual period only. Thus four times she was admitted in DKA during her menstrual period only. In between she used to take regular insulin, with a strict diet control despite which she used too develop DKA. She was discharged with the advice to take small dose of regular insulin frequently atleast four times during menstrual period.
Discussion
This is a case of diabetic female who used to have hyperglycemia with ketosis during menstrual period only.
It is said that liability of premenstrual hyperglycaemia is most marked in adolescence but it may occur at any age. If it is episodic monthly than it certainly has an endocrinal basis. Though later on it may be complicated by emotional factors.
Effect of menses upon glycosuria and hyperglycemia was studied in girls at Clara Barton birth place camp(2) which showed that with unchanged insulin doses in the diabetic group, glycosuria appeared to be greatest in premenstrual and menstrual period and subsequently becoming normal and easy to control with twice a day insulin injections.
The treatment of brittle diabetics is good dietary advice, and reorganization of insulin regimen in the form of frequent small 3-4 insulin injections.
Apart from this there are other causes of brittle diabetes like therapeutic errors either by physician or patient in the form of inadequate doses, improper time of insulin, imperfect dietary advises or some times emotional stress like home disturbances or family conflicts leading to some neuroendocrinal disturbances which by triggering counter regulatory response lead to unstability of blood glucose level or an intercurrent illness like PTB, thyroid, adrenal hypo or hyperfunction or GIT absorption defects may cause brittle diabetes and here the treatment of cause will resolve the problem of these diabetics.
Sometimes diabetic patient induce hypo or hyperglycaemia by contrived manipulation of dose of insulin more commonly the young females and are difficult to deal. The newer techniques of insulin administration may give a relative stability e.g. automatic insulin pump implanted subcutaneously which will supply insulin i/v at the rate required.
Sometimes the cause for ^instability of blood glucose level is not found; probably fluctuating levels of antibody against the insulin receptors, a cause yet to be proved.
Thus there are many causes described for brittle diabetes leading to unstability of blood glucose which may be treated according to cause.
REFERENCES
1. J.J.Bell, TDR Hockaday, Page 1496, Chapter 11:11. 2. Oxford Text Book of Medicine
Vol 2, 3rd edition. Oxford Medical Publication.
2. Joslin diabetes mellitus llth edition Page 243. Chapter 13, Len Febigot Publication.
3. Heller simon diabetes review international, Vol.-4 No.2, April 1995.
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