This 19-year old girl who was massively overweight presented to the hospital for uncontrolled diabetes. When weighed in the hospital, she turned out to be 390 pounds. She looked much older than 19. If not for the age mentioned in the chart, I would have said this was a middle-aged woman.
But, upon getting to know her better, she still smiled, laughed and behaved like a kid. She insisted she had been good with her diabetic diet and hadn't skipped any medication doses. Her mother confirmed this was indeed the case.
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As it was, there was no apparent medical reason why this girl's diabetes was out of control. And it didn't end there. Over the next few days, the girl continued to run blood glucose values in excess of 300, in spite of a hefty increase in her insulin dosage. Medically, I was at a loss. I knew that certain conditions, such as active infections, can bring diabetes out of control. However, this girl did not appear to have any active infection. She wasn't running a fever, and denied having anything out of the ordinary happen to her prior to her arrival to the hospital.
And then one day, by a twist of events, we found it. While mowing things over with the patient and her mother, I noticed a slight odor coming from under the girl's blanket. I lifted the blanket to look for the cause of this odor, which appeared to emanate from the girl's thigh.
With her being so severely overweight, there was massive cellulite buildup on both thighs. The left thigh in particular had a huge skin fold, which on closer examination appeared to be the source of the odor. Upon lifting this skin fold and pushing it all the way back (no small undertaking, since it probably weighed about 25 pounds), it became apparent there was an infected skin area deep inside the fold, oozing yellowish pus.
So that was it! We had found the infection. Both the girl and her mother were shocked to hear my findings. They never knew about it. The infected area was too far removed for the girl to even reach it. Which means it never got washed and never got cleaned. A perfect breeding ground for bacteria.
After starting antibiotic treatment and local skin care, the girl's thigh wound improved markedly. And, as the infection abated, her blood sugar levels quickly returned to baseline.
But most importantly, this patient realized the risks of being overweight. A nutritionist worked with her to devise a reduced calorie diabetic diet. The girl understood this was a long-term process, and that multiple gradual calorie reductions would be necessary over time, until she reached her final steady state condition. However, if this patient stuck with the plan over time, her prognosis should be favorable.
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