Steroid-induced Diabetes Complicating Treatment of Epidermolysis Bullosa Acquisita: A Preventable Treatment Complication Stresses the Importance of Primary Care Follow-up

Abstract

Epidermolysis bullosa acquisita is a rare autoimmune bullous disease involving the skin and mucosa, most commonly treated with systemic corticosteroids. This case illustrates the importance of counseling patients on medication side effects and ensuring close physician follow-up during an extended course of steroids. A 46-year-old man presented to the emergency department with weakness, fatigue, dizziness and polyuria in the setting of eight weeks of prednisone therapy for a flare-up of his bullous disease. Labs were significant for a blood glucose of 786 mg/dL, negative urine ketones, a normal anion gap, and an acute kidney injury. Blood glucose improved to 413 mg/dL after initial treatment with fluid and insulin. The patient was admitted and acute kidney injury resolved. He remained hyperglycemic despite his adjusted prednisone taper and corrective scale insulin, so basal and scheduled, pre-prandial insulins were added. After discharge, he was bridged to steroid-sparing therapy (rituximab). Physicians should counsel patients with epidermolysis bullosa acquisita about the risks of steroid-induced diabetes mellitus and its associated complications including hyperglycemic hyperosmolar state and diabetic ketoacidosis. Primary care physicians should screen for hyperglycemia during therapy and consider alternative treatments when necessary.