DAPAGLIFLOZIN ASSOCIATED EUGLYCEMIC DIABETIC KETOACIDOSIS: A CASE REPORT

SGLT2 inhibitors are a new class of drugs for lowering blood sugar levels in type 2 diabetics. They have been shown to reduce cardiovascular risk along with improving glycemic control. Some of the SGLT2 inhibitors are Canagli?ozin, Dapagli?ozin, Empagli?ozin, Ertugli?ozin, Remogli?ozin. We are presenting a case of a 60-yearold female patient who is a known case of Type 2 Diabetes Mellitus presented to the emergency room with loss of responsiveness for 1 day gradual in onset. Her history revealed she is type 2 diabetic for the past 10yrs and was hospitalized 20days back when her RBS was 889mg/dl & urine ketones were positive with a diagnosis of type 2 DM with DKA. since then, she was put on Tab Dapagli?ozin 10mg OD along with other OHA's. On presentation, the patient was unconscious GCS-E1, V2, M2-5/15, pulse3 100/min, BP-80mm of hg systolic, glucometer RBS-211 mg/dl, ABG showed severe metabolic acidosis pH-6.86, HCO -2.9mmol/L, 2 PCO -24mm hg, PaO2-58mm hg, urine ketones came positive, and the patient was managed conservatively. The patient responded well, and her GCS improved with stabilization in her condition. Dapagli?ozin and other SGLT2 inhibitors can cause Euglycemic DKA, and these can be missed out in the emergency room as they have not so high blood sugar levels making the diagnosis of DKA dif?cult in emergency conditions

DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic

ABSTRACT We assess the severity and frequency of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) patients and in patients with previous diagnosis of T1D in a referral Brazilian university hospital in the first five months of the COVID-19 pandemic. We also compare the data with data from pre-pandemic periods. Forty-three new-onset T1D patients were diagnosed between April and August of the years 2017, 2018, 2019, and 2020. During the COVID-19 pandemic, the number of new-onset T1D was over twice the number of new-onset T1D in the same period in the three previous years. All the 43 patients survived and are now on outpatient follow-up. We also compared the characteristics of the T1D patients hospitalized between April and August of the years 2017, 2018, and 2019 (32 hospitalizations) to the characteristics of the T1D patients hospitalized between April and August/2020 (35 hospitalizations; 1 patient was hospitalized twice in this period). Fourteen of the 34 patients admitted during the pandemic presented with COVID-19-related symptoms (any respiratory symptom, fever, nausea, vomiting, and diarrhea), but only one had positive SARS-CoV-2 RT-PCR test. Samples from 32 out of these 34 patients were assayed for SARS-CoV-2 antibodies, and four patients were positive for total antibodies (IgM and IgG). In agreement with recent reports from European countries, we observed increased frequency of DKA and severe DKA in new-onset and previously diagnosed T1D children and adolescents in a large referral public hospital in Brazil in the first five months of the COVID-19 pandemic. The reasons for this outcome might have been fear of SARS-CoV-2 infection in emergency settings, the more limited availability of primary healthcare, and the lack of school personnel's attention toward children's general well-being.

Recurrent diabetic ketoacidosis

ABSTRACT Objective The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. Materials and methods Review article. Results Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. Conclusions Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Awareness about diabetes mellitus and DKA among medical students: an observational study

Background: Diabetes Mellitus (DM) is a global epidemic and a leading cause for increased mortality and morbidity. The prevalence of Diabetes is very high so the management of DM and its complication like diabetic ketoacidosis (DKA) is very crucial in today’s world. Medical students being the future pillars of our health care system were included in this study to know their knowledge towards diabetes and its acute complication DKA.Methods: This study was a questionnaire based observational study conducted in Adichunchanagiri Institute of Medical Sciences, B G Nagara. Final year medical students and interns were included in the study.Results: A total of 150 (75 from each group) questionnaires were collected and analysed. Most of the final year students and interns were aware about the classical symptoms of diabetes (73.33% and 84% respectively) and were aware about the endocrine gland related to diabetes (82.6% and 94.6% respectively) however there were differences about the meaning of PPBS among both the groups. Interns (76%) had better knowledge regarding the fluid replacement in the management of DKA in compared to final year students (41.33%). There was statistically significant difference in knowledge between the two groups regarding GDM.Conclusions: This study identifies that both final year students and interns need to improve the practical knowledge towards diagnostic parameters of DM and treatment of DKA. Continous medical education programmes and workshops should be organised to enhance the knowledge towards DM and its complications.

Fulminant type 1 diabetes associated with pregnancy:A case report and review of the literatures / 中国糖尿病杂志

[Summary] Fulminant type 1 diabetes (F1D) which is characterized by the abrupt onset of disease , severediabetic ketoacidosis ,high serum pancreatic enzyme concentrations ,and absence of diabetes‐related antibodies is classified astype 1B diabetes. T1DM that developed during pregnancy were mostly F1D. Once occurred ,it would lead to severe outcomes such as stillbirth and death of gravida. One case of pregnancy combined with F1D is reported in this article. We discussed the incidence ,pathogenesis and diagnosis of the disease ,aiming at strengthening the awareness of the disease and also improving the prognosis.

Case Report of Everolimus-Associated DKA in a Patient with Metastatic Renal Cell Carcinoma / 대한내과학회지

Everolimus, an inhibitor of the mammalian target of the rapamycin (mTOR) pathway, is widely used as an immunosuppressant for the prevention of organ rejection following transplant and to treat metastatic clear-cell type renal cell carcinoma (RCC), breast cancer, and pancreatic neuroendocrine tumors. Everolimus commonly induces metabolic abnormalities such as hyperglycemia, hypercholesterolemia, and hypertriglyceridemia due to concomitant increases in blood glucose levels via the induction of insulin resistance and a decrease in beta cell function, which both lead to insulin deficiency. Although abnormal blood glucose levels are observed in more than 50% of patients treated with Everolimus, hyperglycemia exceeding 500 mg/dL is not common and there have been no reports of Everolimus-induced acute hyperglycemic crisis conditions. Here, a novel case of Everolimus-associated diabetic ketoacidosis (DKA) in a patient with RCC is reported.

Analysis of 36 cases of diabetic ketoacidosis with increased trypsin / 中国基层医药

Objective To explore the rising degree of hemodiastase,lipase and the relationship with acute pancreatitis with diabetic ketoacidosis(DKA).Methods 36 diabetic ketoacidosis patients with increased trypsin were divided into non pancreatitis group(20 cases)and pancreatitis group(16 cases)based on the results of abdominal CT.And the blood amylase,urine amylase,blood fat enzyme levels of the two groups were measured and compard.Results The blood amylase of the pancreatitis group was(275.0±10.5)U/L,and that of pancreatitis group was(615.4±17.8)U/L,the difference between two groups was obvious(P＜0.01);The blood lipase of pancreatitis group was(2125.0±50.4)U/L,and that of pancreatitis group was(2021.0±19.8)U/L,there was no significant difference between the two groups(P＞0.05).The blood amylase and abdominal CT results compliance high.Conclusion Pure DKA can cause diabetes pancreatic enzyme increases,and in the diagnosis of acute pancreatitis,the specificity of blood amylase is high.

Acute limb ischaemia in a septic patient with diabetic ketoacidosis / Isquemia aguda de miembros en un paciente septico con cetoacidosis diabetica

This is a patient with septicaemia and diabetic ketoacidosis who developed an acute ischaemic lower limb from an arterial thrombus. The patient had decreased protein S function.

Se trata de un paciente con septicemia y cetoacidosis diabética que desarrolló una isquemia aguda en un miembro inferior a partir de un trombo arterial. El paciente presentaba función disminuida de la proteína S.

A Typical Case of Child Abuse: A Case Report.

Child abuse is common but still unnoticed, undiagnosed, neglected childhood problem in Nepal. Child abuse has diverse clinical manifestation ranging from minor injury to severe head trauma to simulating severe medical problem. The true incidence of intentional head injury in children remains uncertain in Nepal. We are reporting a case of child abuse with blunt head trauma with intracranial hemorrhage presenting as a loss of consciousness simulating as a diabetic ketoacidosis (DKA)

Different characteristics of diabetic ketoacidosis between type 1 and type 2 diabetes patients in Malaysia

Background: Diabetic ketoacidosis (DKA) is increasing in patients with type 2 diabetes in Asian countries. However, there is little information regarding the frequency and characteristics of DKA for Malaysian population. Objective: To identify the different clinical and biochemical features of DKA between adult patients with type 1 and type 2 diabetes. Methods: A cross-sectional, retrospective study was performed at University Malaya Medical Centre (UMMC) between January 2000 and December 2005. All patients (aged \>18 years) with type1 or type 2 diabetes were included in this study. Clinical and biochemical characteristics of DKA were studied. Precipitating factors for the development of DKA were also identified. Results: One hundred and twenty patients (61.9%) presented with DKA had type 2 diabetes. Both type 1 and type 2 patients had similar symptoms. Nausea (44.0%) and vomiting (66.4%) were most common symptoms of DKA. Infection (40.5%) was main precipitating factors of DKA. Blood pH level in previously-diagnosed type 1 diabetes patients was lower than that in previously-diagnosed type 2 diabetes (7.18±0.18 vs. 7.26±0.16, p \< 0.0001). Conclusion: A high proportion of DKA occurs in patients with type 2 diabetes. DKA developed severely in newly-diagnosed type 2 diabetes patients more than in previously-diagnosed type 2 diabetes patients.

The Changes of Serum Potassium and Acid-Base Balance in Diabetic Ketoacidosis(DKA) / 대한신장학회잡지

OBJECTIVE: The biochemical data of 10 patients admitted with diabetic ketoacidosis(DKA) during the last 2 years were analyzed for the disturbances of serum potassium(K) and acid-base balance with a special interest to look for the underlying causes of potassium(K) disorder, retrospectively. METHODS: Arterial blood gas analysis was done and electrolytes, serum glucose, serum osmolality, BUN, creatinine were checked on admission and recovery in 10 patients with diabetic ketoacidosis. RESULTS: The mean(+/-SE) serum K at diagnosis and on recovery was 4.9+/-0.9mEq/L(range, 3.2-6.5 mEq/L) and 3.8+/-0.2mEq/L(range, 3.0-4.3mEq/L), respectively. Hyperkalemia(>5.0mEq/L) in 30%(3/10) and hypokalemia(<3.5mEq/L) in 10%(1/10) was noted on admission, whereas, on recovery, hyperkalemia in none and hypokalemia in 40%(4/10). Initial K levels showed a negative correlation with pH(gamma= -0.62, P=0.05) but no significant correlation was found between the initial K levels with anion gap (AG), with serum glucose value and with blood osmolality. Only 40%(4/10) had a simple metabolic acidosis while 60%(6/10) had a mixed acid-base disorder DKA with respiratory alkalosis, mostly(5/6). The ratio of delta AG over delta HCO3 was not significantly different between patients with a simple metabolic acidosis(0.95) and with a mixed acid-base disorder(0.92). CONCLUSION: The degree of acidosis must be one of the predominant factors in the pathogenesis of the initial hyperkalemia rather than hyperglycemia resulting from insulinopenia itself. Also, we observed that patients with DKA commonly develop mixed acid- base disorders, and delta AG/delta HCO3 ratio would not be an useful tool to look for a mixed acid-base disorder.

THE ACTION OF INSULIN-COUNTER HORMONES IN THE PATHOGENESIS OF DIABETES KETOACIDOSIS / 西安交通大学学报(医学版)

Diabetic Ketoacidosis (DKA) is a condition biochemically characterized by the combination of hyperglycemia, hyperketonemia and acidemia. The extracellular concentration of glucose and ketone bodies in human body can respectively increase 5 and 20 times as more as usual, and the pH of arterial blood can decrease below 7.0. Accumulation of gluccse, ketone bodies and hydrogen must be due to the imbalance of the rate of production, ulilization, and excretion of these substance. In DKA, the metabolism of several hormones and substances is probably involved in the initiation and maintenance of ketone body over-production. At present, 14 patients with DKA have been investigated and it has been found that relative insulin deficiency appears to be necessary, and the excess production of growth hormone, glucagon and catecholamincs (the urine adrenaline and noradrenaline were measured) may be also important in the pathogenesis of DKA.