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Case Reports

Abstract

A 10-year-old boy with type 1 diabetes mellitus (A1C 7.9) and IgA deficiency presented with progressive, asymptomatic depressions on his bilateral hips and buttocks for over one year. The lesions were not associated with trauma but were located near areas where the patient wore his AutoSoft 90 insulin infusion kit and Dexcom G6 Continuous Glucose Monitor. Physical exam revealed well-circumscribed, depressed, skin-colored, non-scaly, firm plaques; the largest was 4 cm x 3 cm with prominent vasculature. Other than ANA (titer >1:1280, speckled), HLA-DQ2, and HLA-DQ8 positivity, the patient lacked systemic, cutaneous, and serologic findings of autoimmune connective tissue diseases. The clinical differential included acquired localized lipoatrophy related to diabetes, versus lipodystrophy or panniculitis related to lupus and less likely scleroderma. A punch biopsy demonstrated reduction in the size of adipocytes in the subcutis with no inflammation. Lipodystrophy—with lipohypertrophy being more common than lipoatrophy—is known to be associated with diabetes mellitus and insulin administration, especially in the setting of chronic insulin use and inadequate rotation of injection sites. The pathogenic mechanism and role of autoimmunity are unclear. Classically, lesions are distributed at sites of insulin injection. Notably, our patient’s lesions were not at sites of direct injection or trauma. Prompt diagnosis of this incurable condition based on clinicopathologic correlation is critical for ruling out connective tissue disease in patients with atypical distribution and higher risk of autoimmunity. Diagnosis can help inform diabetes management, as lipodystrophy may be associated with increased insulin resistance and other metabolic abnormalities.