Autologous skin grafting--a limb-saving procedure in a patient with diffuse cutaneous systemic sclerosis.

Chronic CQ treatment enhances insulin release in rats [5]. Animal data have shown that adding HCQ to streptozotocintreated diabetic rats led to a higher insulin level and lower glucose concentrations. HCQ may reduce cytosolic insulin metabolism [6, 7]. HCQ is an anti-malarial drug that may have anti-hyperglycaemic properties in patients with type 2 diabetes mellitus and the benefical effects on glucose metabolism and insulin sensitivity was reported among patients with SLE [8, 9]. HCQ improves glycaemic control in sulphonylureas refractory patients with poorly controlled type 2 diabetes [8]. The addition HCQ to insulin therapy caused a significant decrease in the insulin requirements [8]. This effect appeared at 2 weeks and persisted for 6 months. In a prospective, multicentre, observational study, Wasko et al. [10] showed that 4905 RA patients using HCQ is associated with a reduced risk of diabetes. HCQ may be indicated for the prevention of hyperlipidaemia and diabetes mellitus [10, 11]. Although HCQ use reduces the need for oral anti-diabetic and insulin in patients with type 2 diabetes mellitus, hypoglycaemia may develop in non-diabetic patients with RA. Therefore, fasting blood glucose and HbA1c levels should be monitored during the first 6 months of treatment for symptomatic and asymptomatic patients, respectively. We came to notice that our patient was suffering mild symptoms of hypoglycaemia, only after he had started receiving HCQ for RA treatment. This being the case, we suggest that patients who are to receive HCQ should be well informed about such ill-effects of HCQ as hypoglycaemia.