慢性移植片対宿主病による皮膚障害に対してインスリン皮下注射実施に工夫を要したステロイド糖尿病の1例  [in Japanese] A Case of Glucocorticoid-Induced Diabetes Mellitus With Devised Subcutaneous Insulin Injection for Skin Disorders Due to Chronic Graft-Versus-Host Disease (GVHD)  [in Japanese]

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Author(s)

    • 鈴木 和代 Suzuki Kazuyo
    • 京都大学大学院医学研究科糖尿病・内分泌・栄養内科学 Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University
    • 原島 伸一 Harashima Shin-ichi
    • 京都大学大学院医学研究科糖尿病・内分泌・栄養内科学 Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University
    • 大島 綾子 Oshima Ayako
    • 京都大学医学部附属病院疾患栄養治療部 Department of Metabolism and Clinical Nutrition, Kyoto University Hospital
    • 陳 豊史 Chin Toyofumi
    • 京都大学大学院医学研究科呼吸器外科学 Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University
    • 伊達 洋至 Date Hiroshi
    • 京都大学大学院医学研究科呼吸器外科学 Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University
    • 稲垣 暢也 Inagaki Nobuya
    • 京都大学大学院医学研究科糖尿病・内分泌・栄養内科学 Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University

Abstract

症例は24歳,女性.17歳時に急性骨髄性白血病を発症し非血縁者間骨髄移植を施行され寛解した.21歳時に全身性に皮膚GVHD(graft-versus-host disease)を発症しタクロリムス,ステロイドを開始された.24歳時に肺GVHDに対して生体肺移植術を施行され拒絶反応に対するステロイドパルス療法後に高血糖となりインスリン療法が必要となったが,皮膚GVHDのため頻回皮下注射の導入は容易ではなかった.大腿内側部に1日2回の皮下注射と経口血糖降下薬を併用且つ消毒範囲を小さくし皮下注射の継続が可能となった.移植後長期生存例の増加とともに慢性GVHDは増加しているが,皮膚GVHDに対するインスリン皮下注射に関する報告は少ない.本症例は,注射回数,注射部位,スキンケアを工夫することでインスリン療法が継続でき,患者の精神的な負担も軽減させ,治療意欲の向上にも寄与した貴重な症例であり報告する.

Subcutaneous insulin injection is problematic for diabetes mellitus patients complicated with chronic skin graft-versus-host disease (GVHD) because of their fragile skin. We herein report a therapy regimen including subcutaneous insulin injection in a 24-year-old woman with glucocorticoid-induced diabetic and chronic skin GVHD. The patient had undergone an unrelated bone marrow transplant for acute myeloid leukemia at age 17 and developed chronic GVHD-associated scleroderma and bronchiolitis obliterans at age 21. At age 24, she received a bilateral lung transplant from a living donor and pulse steroid therapy to control rejection. Her blood glucose level rose to over 200 mg/d<i>l</i>, and insulin treatment was required. However, providing multiple insulin injections was difficult due to the patient's anxiety as well as subcutaneous bleeding and skin scarring. The number of injections was reduced to twice daily, with pre-mixed insulin 50:50 at breakfast and a rapid-acting insulin at dinner, in combination with 90 mg of nateglinide at lunch. The skin was protected by minimizing the sterilized area. This regimen encouraged the patient and permitted the continuation of insulin therapy. This case suggests that adjusting the insulin formulation and number of injections in combination with oral anti-diabetic therapy and specific skin care can permit successful insulin treatment in cases of diabetes complicated with skin GVHD.

Journal

  • Journal of the Japan Diabetes Society

    Journal of the Japan Diabetes Society 58(8), 558-563, 2015

    THE JAPAN DIABETES SOCIETY

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