The 74 year, male, tobacco chewer, veterinary Doctor was under treatment for diabetes and hypertension since last 5 years by a diabetologist. Four months ago his sugar control went out of control. 24-hour sugar study was done by diabetologist blood reports. As per the reports has baseline sugar fluctuations has increased, HbA1c 7.5%, ESR 75. As per his diabetologist opinion, he was started on three OHA -(GLICLAZIDE, METFORMIN, SITAGLIPTIN AND ONE DOSE INSULIN TRESIBA 8 UNITS.)
As the patient was known, so came to me with reports for casual second opinion at the same time 4 month ago for getting endorsed that all is well. I wish to get some more reports which his diabetologist said no, saying that all these changes are due to uncontrolled diabetes and once diabetes gets under control all the reports will be ok.
So I wanted to find out the reason for high ESR and fluctuating uncontrolled sugar. TB and malignancy were high in my card so I ask them to get a screening PET -CT has done. The request was turned down by diabetologist and he was very particular in saying that let us wait till sugar in under control and ESR will come down and ESR is a non-specific test.
Then two month ago, on three antidiabetic drugs and tresiba his sugar got under control, HbA1c =6.5 and ESR CAME DOWN TO 45. I was still persistent for PET CT- Request declined.
A week ago a patient came with 5 kg weight loss, SGPT 95, ALK PHOSPHATASE 154, BILIRUBIN 1.8. ESR again rose to 74. ( All these reports patient was getting it done himself -in view of routine checks)
I got his CA-19-9( 38- high normal) MDCT abdomen and MRCP done, which showed an inoperable CA Pancreas. Endoscopic USG biopsy showed high-grade Adenocarcinoma.
Lesson – 1-High ESR in diabetes is not a normal finding.
2-Whenever sugar goes out of control in well-managed diabetes find the treatable causes and precipitating factors rather adding three or four drugs.
