case_images: PMC6393920_01
case_images: (a) An abdominal computed tomography scan performed on the patient's first visit shows diffuse swelling extending from the pancreatic body to tail. The arrow indicates the affected portion of the pancreas. (b) Magnetic resonance image (T2 weighted image) of the abdomen prior to prednisolone therapy reveals diffuse swelling extending from the pancreatic body to tail. (c) MRCP prior to prednisolone therapy shows narrowing of the main pancreatic duct extending from the pancreatic body to tail.
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case_images: PMC6393920_01_CRIE2019-9415347.001.jpg
case_images: fig1
case_images: Abdominal computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography (MRCP) revealed diffuse swelling that extended from the pancreatic body to tail (Figures 1(a)-1(c)). In addition, MRCP showed narrowing of the associated main pancreatic duct (Figure 1(c)).
case_images: The results of continuous glucose monitoring (CGM) with the flash glucose monitoring system. Closed arrowheads indicate the timing of the patient's meals and insulin injections. Open arrowheads indicate the timing of the patient's insulin injections before sleep. Values adjacent to the arrowheads indicate the number of units of insulin injected. (a) One representative pattern of CGM prior to initiation of prednisolone. (b) Initiation of 35 mg/day of oral prednisolone. (c) Two days after initiation of prednisolone. Total dosage of insulin was increased to 52 units/day. (d) Because of the amelioration of AIP, prednisolone dosage was reduced to 25 mg/dL; however, 42 units/day of insulin was required to maintain glycemic control. (e) First day of empagliflozin administration. Hypoglycemia recorded at 5 AM to 6 AM and approximately 8 PM. (f) Twenty days after empagliflozin initiation. (g) CGM pattern of patient on empagliflozin only.
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case_images: PMC6393920_01_CRIE2019-9415347.002.jpg
case_images: fig2
case_images: By the end of April, the patient's total insulin dosage was 36 units/day (Figure 2(a)). AIP. At that time, 42 units/day of insulin was not sufficient to control glucose elevation (Figure 2(b)); the patient required a maximum of 52 units/day (Figure 2(c)). However, 42 units/day of insulin was required to maintain glycemic control (Figure 2(d)). Nevertheless, the patient experienced hypoglycemia 1 hour after breakfast and 1 hour after dinner on the day of empagliflozin initiation (Figure 2(e)). By the end of June, 20 days after the addition of empagliflozin, the patient had lost 1.2 kg and his total insulin dosage had declined to 20 units/day (Figure 2(f)). Because the patient had achieved good glycemic control (postprandial glucose, HbA1c, and glycoalbumin levels: 159 mg/dL, 6.9%, and 14.3%, respectively), the total dosage of insulin was further reduced and then eventually discontinued (Figure 2(g)).
case_images: Changes in glycemic control and clinical course of AIP during prednisolone therapy. HbA1c levels (circles) and serum IgG4 levels (squares) declined over the course of treatment.
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case_images: PMC6393920_01_CRIE2019-9415347.003.jpg
case_images: fig3
case_images: HbA1c levels: 130-180mg/dL and 5.4-5.8%, respectively) despite receiving only empagliflozin for diabetes (Figure 3). However, his postprandial C-peptide level remained low (1.84 ng/mL), revealing that although the insulin-secreting capacity of his pancreas had slightly recovered, it remained insufficient.
case_images: (a) Magnetic resonance image (T2 weighted image) of the abdomen after prednisolone therapy reveals amelioration of the diffuse swelling that had affected the pancreas from body to tail. (b) MRCP after prednisolone therapy revealed amelioration of the narrowing of the main pancreatic duct.
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case_images: PMC6393920_01_CRIE2019-9415347.004.jpg
case_images: fig4
case_images: His follow-up magnetic resonance imaging and MRCP showed that both the diffuse swelling of the pancreatic tail and narrowing of the associated main pancreatic duct had been ameliorated (Figures 4(a) and 4(b)).