Severe insulin resistance in long-term acute leukaemia survivors: lesson learned from a clinical case and review of the literature.

With the improvement of haematopoietic stem cell transplantation(HSCT) and radiotherapy, the population of cancer survivors isincreasing and therefore increasing the number of patients livingwith late metabolic complications. We describe a case of a child-hood acute lymphoblastic leukaemia survivor who developedinsulin resistance 10 years after HSCT and total body radiation re-quiring a high dose of insulin (>1,500 IU). Using insulin-sensitisingagents metformin and thiazolidinediones improved the control andreduced the insulin requirement – eventually stopping insulin. Wedescribe for the first time the phenomenon of reverse diurnalvariation in insulin sensitivity based on the clinical picture alone,which has not previously been described in the literature. We havereviewed the plausible mechanisms of developing insulin resistance,reverse diurnal variation and the role of thiazolidinediones inreducing lipotoxicity and adipocyte differentiation resulting inimproved insulin sensitivity in such cases.