Question of the Week # 177

Q177) A 52 Year old obese man is evaluated in your office during a routine annual visit.  He denies any fatigue or recent weight changes. He has normal appetite and physically active. He had a colonoscopy 1 year ago that was normal. On physical examination, he is obese with a BMI of  34. Skin examination reveals the findings shown in the image below :

Which of the following is most likely to be seen in this patient?

A) Diabetes Mellitus, Type I

B) Gastric cancer

C) Increased Insulin levels

D) Hyperthyroidism

E) Addison’s disease

12 Responses

  1. ccccccccc ,acanthosis nigrans

  2. this is interesting b/c if not obese——-its can be a sighn of malignancy
    since he is obese we can answer the question with high insulin levels
    with resistance

  3. Acanthosis…DM…..high insulin resistence

  4. c

  5. plz gve Answer!

  6. answer is E

  7. Very good one !
    the answer is increase insulin level 🙂 , most commonly in DM type 2

    If we did not pay attention , we might be trick into picking diabetes mellitus type 1 . ( lack of insulin) hahaha

    Addison is highly unlikely , have to have other symptoms of adrenal insufficiency . Or ass with other autoimmune disease .

    Gastric cancer is not the answer : patient is obese . No weight loss .

  8. acanthosis nigrans. associated with obesity and insulin resistance. answer is ccc

  9. What is shown is localized hyperpigmentation of the skin also called Acanthosis nigricans descriptively. Acanthosis means epidermal hyperplasia or thickening of the skin. And ‘nigrican describes the dark to black color of the affected skin.
    Acanthosis nigricans is the result of over-stimulation of keratinocytes and melanocytes receptors by growth factors. Insulin, Growth hormone, ACTH, TSH, Tumor Necrotic factor are some of the chemical stimulants of the growth.
    In an obese patient, there is insulin resistance and there is excess of circulating insulin that is thought to be responsible for this frequently observed association between obesity and acanthosis nigricans. Therefore, in this patient, the most likely additional finding is elevated insulin levels.
    When we see the skin finding of Acanthosis nigricans in a patient, the next question is what is responsible for the stimulation of the epidermal cells. In this patient, obesity and insulin resistance stand out.
    In a different scenario, with different risk factors, stomach cancer (option B), hypothyroidism (option 1/D), type 2 DM (option 1/A), or Addison’s disease (option E) may be more appealing.
    The clinical significance of Acanthosis nigrican is that some of these lesions occur because of an underlying cancers, most commonly gastrointestinal cancers. And we have to exclude paraneoplastic syndrome and risk factors for cancer. In these patients, tumor necrotic factors stimulate the epidermal cell growth. In this patients however, out of all the options, the most likely additional finding will be elevated levels of insulin ( Option C)

    My answer is Option C.

  10. isn’t insulin resistant associated with insufficient production of insulin? so why would it be high insulin level, C?

    • In the initial stages of chronic hyperglycemia, your pancreas tends to overwork itself to compensate and attempt to achieve normoglycemia. Eventually, you reach a stage of insulin resistance. This does not mean that insulin levels are low. Low insulin levels are when the pancreas becomes burnt out. Initial management of mild diabetes includes increasing insulin sensitivity (metformin; it also decreases hepatic gluconeogenesis) or increasing insulin release from the pancreas (sulfonylureas – ie pancreas work harder!).

      • Marty pls make sure you read these references. http://care.diabetesjournals.org/content/31/Supplement_2/S262.full
        http://www.ncbi.nlm.nih.gov/pubmed/15733362
        http://www.ncbi.nlm.nih.gov/pubmed/14651545

        Especially the first one, in which, the relationship of hyperinsulinemia with obesity is explained. The second and third references talk about relationship of hyperinsulinemia and Acanthosis nigricans.

        The truth is that no one is sure of the etiology of high blood sugar, diabetes type 2 and hyperinsulinemia as well as hypertension in obese patients but it is like the mighty mystery or the chicken and the egg mystery. Something happens and people start to become obese and at some point, just like blood pressure, their blood sugar and insulin is also found to be elevated. One thing is sure, insulin is elevated when higher amount of it is needed to stimulate the target tissue – In this case , the MASSIVE adipose tissue that is blatantly refusing to accept any more storage.

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