Patient: Male, 58-year-old Final Diagnosis: Diabetes mellitus type 2 Symptoms: Confusion • diaphoresis • dizziness • dyspnea • palpitation • weakness Medication: Metformin Clinical Procedure: — Specialty: Endocrinology and Metabolic • General and Internal Medicine • Psychiatry Objective: Unusual clinical course Background: Metformin has a longstanding reputation as the first-line treatment for glycemic control in the setting of diabetes mellitus type 2. A contributing factor to this reputation is metformin having a low risk of inducing hypoglycemia compared to other oral hypoglycemics or insulin. There are no case reports of hypoglycemia while on conventional or therapeutic doses of metformin. This case report is of a patient who developed symptomatic hypoglycemia while being treated with a therapeutic dose of metformin. Case Report: A 58-year-old man with history including diabetes mellitus type 2, hypertension, and schizoaffective disorder was dismissed early from work due to symptoms of severe weakness, confusion, diaphoresis, dizziness, shortness of breath, palpitations, and a sensation of feeling hot. Continuous glucose monitoring revealed hypoglycemic episodes up to 4% of the time. The hypoglycemic events appeared to occur primarily between midnight and 7 A.M., with the second likely time frame being between 7A.M. and noon. Within 2 weeks of discontinuing metformin, there were no further “attacks”, and the chronic daytime fatigue and somnolence significantly improved. Conclusions: This case report suggests that there is a risk of symptomatic hypoglycemia with therapeutic doses of metformin. Although advised to be taken with meals to avoid gastrointestinal upset, patients should also be educated to take metformin with meals to reduce the risk of metformin-associated hypoglycemia.
Patient: Male, 65-year-old Final Diagnosis: Xanthogranulomatous prostatitis Symptoms: Constipation • pelvic pain • tenesmuss • urinary retention Medication: — Clinical Procedure: Biopsy Specialty: General and Internal Medicine • Psychiatry • Urology Objective: Unusual clinical course Background: Xanthogranulomatous prostatitis is rare, with no more than 10 to 15 cases reported to date. The presentation typically includes lower urinary tract or lower urinary tract infection symptoms. The present case report describes a 65-year-old man diagnosed with xanthogranulomatous prostatitis after a prolonged course of atypical symptoms. Symptom remission was achieved with low-dose Cymbalta and 6 weeks of ciprofloxacin. Case Report: A 65-year-old man had a 1-year history of pelvic floor disorder, including treatment-resistant tenesmus and rectal and perineal pain. The patient eventually developed a reduced urinary steam with urinary retention. On digital rectal examination, his prostate was non-tender and had significant firmness on the left side. Magnetic resonance imaging of the prostate with and without contrast showed a Prostate Imaging-Reporting and Data Stem 5 lesion involving the left peripheral zone of the prostate with diffuse enhancement and low signal throughout the gland. Suspicious adjacent lymphadenopathy also was present. The patient’s prostate-specific antigen level was within the normal range at 2.4 ng/mL. All 13 left prostatic biopsy specimens showed acute and chronic inflammatory changes with prominent xanthogranulomatous features and without evidence of necrosis. All of the patient’s symptoms, including pain, resolved after he started taking Cymbalta and completed a 6-week course of ciprofloxacin. Conclusions: The present case report describes an atypical presentation of xanthogranulomatous prostatitis, which started with symptoms of pelvic floor disorder that preceded urinary symptoms by at least 1 year. The patient’s symptoms improved after he started taking Cymbalta and completed a 6-week course of ciprofloxacin, 500 mg twice daily, and without concurrent treatment with an alpha blocker, corticosteroids, or pelvic floor therapy.
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