Presentation
Acute presentation with abdominal pain and distension. Clinical concern of intestinal obstruction or perforation. Background of poorly controlled type 1 diabetes and cognitive impairment following road traffic accident; difficult urinary voiding after this, requiring long term urethral catheter.
Patient Data
Two relatively symmetrical sessile oval soft tissue densities arise from the subcutaneous planes of the lower abdomen; scattered calcifications are noted at their bases.
The other salient acute findings on the CT are massive distension of the urinary bladder, also containing substantial amount of gas. Air present in right renal collecting system. Both ureters and renal pelves are dilated.
A urethral catheter is malpositioned, terminating in the penile urethra. Periurethral gas at this level extends to the corpus cavernosum on the right, consistent with urethral rupture. Prior trauma to left pubic rami.
Abdominal radiograph acquired one year prior to the acute presentation. The two discrete soft tissue densities project over both acetabula, predating the acute hospital admission.
Prominent large bowel loops over the lower lumbar spine, non-specific. Urethral catheter present.
Case Discussion
The subcutaneous masses in the lower abdomen are a good example of lipohypertrophy.
Subcutaneous insulin injection can cause different types of lipodystrophy: lipoatrophy (loss of fatty tissue) is regarded as an aesthetically unpleasant phenomenon, presumed secondary to an autoimmune response 1,2. It is rare with current new generation insulins.
On the other hand, lipohypertrophy relates to repeated injections at the same site and is caused by the effect of insulin on the adipose tissues. It is associated with poor insulin response and erratic blood glucose levels in individuals that do not rotate the areas of administration 3. Patients should be specifically instructed not to inject insulin in those sites.
The management during this emergency admission included placement of a new urethral catheter, accomplished without cystoscopic assistance. A conservative approach was suggested for the urethral injury. The gas in the right kidney was presumed to have refluxed from the bladder itself but an emphysematous pyelitis could not be ruled out on imaging alone. An intravenous course of temocillin was therefore administered accordingly.
Case presented with Radiology Consultant colleagues M Gronski and T Elswood.
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