Muscle relaxant induced pancreatitis leading to hyperosmolar hyperglycemic state.

Muscle relaxants are commonly prescribed in the United States but may have deleterious side effects that are unrecognized by physicians. Here, we report a 55-year-old Caucasian man who developed pancreatitis and a subsequent hyperosmolar hyperglycemic state after being prescribed tizanidine. The patient had untreated hypertriglyceridemia, unbeknownst to the prescribing physician. While hypertriglyceridemia is a widely understood risk factor for pancreatitis, its incidence with tizanidine is not. As an alpha-2 agonist, tizanidine slows gastrointestinal motility by inhibiting gastrointestinal smooth muscle contraction, which could lead to ileus which occurred in this patient. Alpha-2 agonists further contract the hepato-pancreatic sphincter, which may result in obstruction of pancreatic enzyme flow via the pancreatic duct. This patient's case of pancreatitis was precipitated by 2 factors: (i) his use of tizanidine and (ii) hypertriglyceridemia. This case demonstrates that patients presenting with severe hypertriglyceridemia, or other potential risk factors for pancreatitis, should not be prescribed tizanidine.

Mistaken Identity: Missed Diagnosis of Type 1 Diabetes in an Older Adult.

Type 1 diabetes can occur at any age from infancy to elderhood. Patients with hyperglycemia onset at older ages are presumed to have type 2 diabetes, but the misdiagnosis of type 2 diabetes as type 1 diabetes in adults has serious consequences. Medical error in this domain leads to significant patient harm that could be avoided with the correct diagnostic testing. Here, we discuss the case of a 58-year-old man who presented with diabetic ketoacidosis (DKA) at age 51 but was given the diagnosis of type 2 diabetes. During two subsequent admissions for DKA, he suffered severe complications. After his third episode of DKA, antibodies and C-peptide were checked, prompting a change in diagnosis to T1DM. Following a correct diagnosis of T1DM, diabetes education and appropriate treatment, the patient remained free of DKA and had improved glucose control. Under-diagnosis of type 1 diabetes can lead to recurrence of life-threatening episodes of DKA. Anti-GAD antibody and C-peptide testing are under-utilized in the differential diagnosis of type 1 versus type 2 diabetes in adults. This case demonstrates the consequences of the mis-diagnosis of type 1 diabetes as type 2 diabetes. The correct diagnosis is necessary to prevent hospital readmissions, morbidity, mortality and medical errors.

High prevalence of comorbid autoimmune diseases in adults with type 1 diabetes from the HealthFacts database.

BACKGROUND: Patients with type 1 diabetes (T1D) are at risk for other autoimmune diseases (ie, polyautoimmunity). The prevalence and risk factors of this phenomenon have been underreported in adults and ethnic minorities, and data are lacking regarding non-endocrine autoimmune diseases. METHODS: Study population data were gathered from HealthFacts, a deidentified patient database compiled from electronic medical records systems in the US. Patients with an International Classification of Diseases diagnosis code specifying T1D were included in the study, whereas those with a diagnosis of type 2 diabetes were excluded. RESULTS: The cross-sectional study cohort comprised 158 865 adults with T1D (mean [±SD] age 51.4 ± 18.9 years, 52.5% female). The most common autoimmune diseases were thyroid disease (20.1%), systemic rheumatic diseases (3.4%), rheumatoid arthritis specifically (2.0%), and gastrointestinal autoimmune diseases (1.4%). Most of the autoimmune diseases were more common in women (eg hypothyroidism, hyperthyroidism, celiac disease, rheumatoid arthritis, lupus, and Sjögren syndrome). Caucasians were more likely than other ethnicities to have an additional autoimmune disease. The prevalence of autoimmune diseases increased with increasing age, significantly in women, such that 38.5% of women over 80 years of age had an additional autoimmune disease, compared with 17.9% of women aged ≤29 years. CONCLUSIONS: Additional autoimmunity represents a significant comorbidity in patients with T1D. Autoimmune diseases are more common in Caucasians and in women, and increase with age. Clinicians treating patients with T1D should be aware of the risk factors for additional autoimmune diseases.

Bilateral Lower Extremity Paralysis in a Caucasian Male Presenting to the Emergency Department.

Reported is a case of a 39-year-old Caucasian man who presented to the emergency department with sudden onset bilateral lower extremity paralysis after consuming a large amount of carbohydrates and alcohol. A CT, MRI, and lumbar puncture were performed with negative results; lab results showed hyperthyroidism and hypokalemia. The patient was diagnosed with thyrotoxic periodic paralysis. In a patient presenting with sudden onset paralysis and hypokalemia, the emergency physician should include thyrotoxic periodic paralysis in the differential diagnosis and focus on treating and working up the hypokalemia instead of the paralysis.