O-07 Lipodystrophy: A disease to be considered in diabetes clinics
Authors: Helvaci Burcak Cavnar , Saat Hanife , Hepsen Sema , Ozcelik Ozgur , Ucan Bekir , Cakal Erman 
Published: January 2024

Abstract

Introduction
Lipodystrophy syndromes are disorders with no adipose tissue. Lipodystrophy is classified based on the degree of adipose tissue deficiency, distinguishing between partial and generalized forms, and considering if it is inherited or acquired. The condition is characterized by ectopic steatosis, severe dyslipidemia, insulin resistance, and severe comorbidities including uncontrolled diabetes mellitus (DM), acute pancreatitis, hepatic cirrhosis, proteinuria, renal failure, and premature cardiovascular disease. Congenital Generalized Lipodystrophy (CGL, Berardinelli-Seip Syndrome) is inherited autosomal recessively. Four genetic mutations linked to CGL have been identified: AGPAT2, BSCL2, CAV1, and PTRF. This report describes a case of a patient with uncontrolled diabetes and other health conditions. The patient was diagnosed with CGL2 as an adult after admission to our facility.

Clinical Case
This case involves a 43-year-old female patient seeking help for glycemic control and menstrual cycle irregularities. She was diagnosed with DM at 24 and received care at multiple hospitals. Her mother, older brother, and three sisters were diagnosed with DM before the age of 40. Her BMI was 23.4 kg/m2. The physical examination revealed muscularly prominent lipoatrophy in the upper and lower limbs and acanthosis nigricans in the axilla. Additionally, the person had facial features resembling acromegaly, with enlarged extremities and swelling of soft tissues. Blood pressure was regulated with ramipril, hydrochlorothiazide, and amlodipine. She had used various insulin and OAD regimens in the past. Despite this, euglycemia was challenging to achieve, and she frequently needed to be hospitalized for diabetic ketoacidosis. Anti-glutamic acid decarboxylase, anti-insulin, and islet antibodies were negative. HbA1c level was 13.3% and C-peptide level was 2.5 ng/ml. Moreover, grade 3 hepatosteatosis and hypertriglyceridemia were present. Polyneuropathy and diabetic nephropathy were also identified. Acromegaly and cushing syndrome were excluded. After excluding acquired lipodystrophy syndromes, she was consulted to the genetics department for CGL. Next-gen sequencing found a homozygous missense mutation (c.666G&gt;C; p.Met222Ile) in exon 5 of the BSCL2 gene. Following this result, the patient was diagnosed as CGL2. Caloric and fat restricted dietary was recommended. Fat intake was below 20-30% of total energy. The patient was treated with insulin aspart, glargine U300/mL, metformin, alpha lipoic acid, and fenofibrate. The patient's blood glucose was more regulated, did not apply to the emergency department. Family members were also given genetic counseling.

Conclusion
Lipodystrophy is rare however medical professionals must exercise caution and consider lipodystrophy as a possible diagnosis for non-obese individuals who have difficulty maintaining euglycemia, fatty liver disease, and elevated triglyceride levels. The physical examination is crucial for diagnosis.