A 32-year-old male patient came for the management of diabetes mellitus to the Diabetes Centre KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka, South India. He was diagnosed to have diabetes mellitus since 2 years. He had a history of missing insulin doses frequently for extended periods and was never hospitalized after the initial diagnosis. There was no documented episode of diabetic ketoacidosis. He presented with complaints of frequent hypoglycemia, tiredness, loss of bodyweight and appetite and neuropathic symptoms. There was no history hypertension, dyslipidemia, tuberculosis and any other medical illnesses such as alcoholic pancreatitis and hyperparathyroidism. His diet was irregular and erratic. He was nonsmoker and nonalcoholic.
General physical examination showed body mass index (BMI) - 14.72, pulse rate (PR) - 80b/min, blood pressure (BP) - 140/100 mmHg, relative risk - 20 cyc/min. No pallor, icterus, clubbing, lymphadenopathy, edema, and thyromegaly. Systemic examination (respiratory, cardiovascular, and central nervous system) was within normal limits. Per abdomen, examination showed hepatomegaly.
The patient was hospitalized for further investigations and was started with premix insulin oral hypoglycemic agents (OHA) and pancreatic enzyme supplements. Patient tolerated the combination well. On the day admission fasting plasma glucose was 159 mg/dl and 2 h postprandial plasma glucose was 200 mg/dl and HbA1c - 6.7%. During hospitalization his blood sugars were monitored 5 times in a day (fasting blood sugar [FBS], postprandial blood sugar [PPBS], prelunch, predinner, and bedtime random blood sugar [RBS]) and there were no episodes of hypoglycemia. Laboratory investigations revealed that hemogram, liver function tests (LFT), kidney function tests, thyroid and lipid profile were within normal limits. Chest X-ray and electrocardiogram (ECG) findings were normal. Serum amylase (69 U/L) and serum lipase (142 U/L) were within normal limits. Fundus examination showed normal study.
By ultrasonography of the abdomen [Figure 1] it was possible to evaluate the size of the pancreas and also confirm the intraductal location of calculi and the degree of fibrous.
Further, the patient was evaluated with computed tomography (CT) scan of abdomen [Figure 2] it showed chronic calcific pancreatitis with dilated pancreatic duct with intramural calculi with hepatomegaly.
During hospital stay the patient improved clinically and glycemically. On discharge patient was advised to take (i) Two doses of premix insulin, (ii) OHA once a daily and (iii) pancreatic enzyme supplements twice daily. Nutrition counseling and diabetes education (insulin injection technique and self-monitoring of blood glucose) was given to the patient. Later, the patient was followed up at 1st month, 3rd month, and 6th month. He was regular in taking treatment and follow diet and exercise.