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Open access

P Hanson, M Pandit, V Menon, S Roberts and T M Barber

Summary

The case is a 34-year-old woman with long-standing type 1 diabetes mellitus with existing follow-up in the outpatient clinic at the Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, UHCW. She had maintained good glycaemic control and glycaemic stability with basal bolus regimen for many years. She had not developed any diabetes-related complications and had no other co-morbidities. Six months ago, she presented to A&E with sudden-onset, well-localised and severe pain in the right iliac fossa, just lateral to the para-umbilical area. Her biochemistry was normal. Ultrasound scan, however, revealed a right-sided ovarian cyst, which was thought to have caused pain to her. She was discharged from A&E with simple analgesia. On subsequent gynaecological follow-up 4 weeks later, her pain remained severe and examination revealed an exquisitely tender subcutaneous nodule at the same location measuring 2 cm in diameter. Magnetic resonance imaging (MRI) scan at the time revealed a 1 cm mass in the subcutaneous adipose tissue, which co-localised to her pain. The mass demonstrated a central fat signal surrounded by a peripheral ring: observations consistent with fat necrosis. There were other smaller subcutaneous nodules also observed in the left para-umbilical area. Subsequent surgical resection of the main area of fat necrosis was performed. The patient made an excellent recovery and her pain resolved post-operatively. Histology confirmed the presence of fat necrosis. Fat necrosis is a rare complication of s.c. insulin injection. This case illustrates the importance of considering this diagnosis in patients who inject insulin and develop localised injection-site pain.

Learning points

  • Fat necrosis is a rare complication of insulin injections that can manifest with severe, persistent and well-localised pain.

  • Fat necrosis can masquerade as other pathologies causing diagnostic confusion.

  • The imaging modality of choice for accurate diagnosis of fat necrosis is MRI.

  • Histological confirmation of fat necrosis is important.

  • Appropriate management of localised fat necrosis is surgical excision, with avoidance of further insulin injections into the affected area.

Open access

Roghieh Molaei Langroudi, Fatemeh Ghazanfari Amlashi and Mohammad Hassan Hedayati Emami

Summary

Background: Spontaneous ovarian hyperstimulation syndrome (sOHSS) can occur following hypothyroidism. Ultrasonography facilitates diagnosis and monitoring of this syndrome. We describe ovarian sonographic changes in a hypothyroid patient with sOHSS after treatment with levothyroxine (l-T4).

Case presentation: A 15-year-old girl presented with abdominal pain and distension for a few months. On examination, she had classical features of hypothyroidism. Abdominal and pelvic ultrasound revealed enlarged ovaries with multiple thin-walled cysts and mild ascitic fluid. On follow-up, abdominal ultrasound showed significant reduction of ovary size after 6 weeks of initiation of l-T4. Normal ovary size with complete regression of ovarian cysts was seen after 4 months.

Conclusion: Serial ultrasound in sOHSS associated with hypothyroidism showed regression of ovarian cysts and ovarian volume after 4 months whereas in other studies, it is reported to happen in various durations, presumably according to its etiology.

Learning points

  • OHSS can rarely occur due to hypothyroidism.

  • This type of OHSS can be simply treated by l-T4 replacement, rather than conservative management or surgery in severe cases.

  • Ultrasound follow-up shows significant regression of ovarian size and cysts within 6 weeks of initiation of l-T4.

  • Ultrasound follow-up shows normal ovarian size with complete resolution of ovarian cysts 4 months after treatment.