scholarly journals Unusual Presentation of Myxedema Coma in Type 1 Diabetes Mellitus With Hyperglycemia and Polysubstance Abuse

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A971-A972
Author(s):  
Yumna Hamid ◽  
Steven Douedi ◽  
Johnathan Nold ◽  
Raquel Kristin Ong ◽  
Jennifer Cheng ◽  
...  
Keyword(s):  
Type 1 Diabetes ◽  
Mortality Rate ◽  
Mental Status ◽  
White Male ◽  
Altered Mental Status ◽  
Close Monitoring ◽  
Urine Drug Screen ◽  
Metabolic Encephalopathy ◽  
Myxedema Coma

Abstract Background: Myxedema coma is a severe manifestation of hypothyroidism that typicallypresents with altered mental status and requires close monitoring in the intensive care unit dueto 30-60% mortality rate. Clinical Case: A 56 year old white male with type 1 diabetes with recurrent DKA, polysubstanceabuse, Bipolar disorder on lithium and post surgical hypothyroidism presented due to change inmental status after being brought in by sister. Patient was found to be lethargic with confusionthat worsened over the last week. The patient was admitted several times in the past monthsecondary to pneumonia, sepsis, and recurrent DKA. On physical examination, he found to have lethargy, macroglossia, hyporeflexia, and periorbitaledema. Patient had acute respiratory failure with metabolic encephalopathy, bradycardia,tachypnea, severe hyperglycemia, hypotension of 77/51, tachypnea of 31 breaths per minuteand hyponatremia. Laboratory findings showed T4 levels 2.87(n=5.28-9.87ug/dL) withundetectable FT4 and elevated TSH (>50, n=0.300-4.500uIU/mL). Electrolyte panel showedhyponatremia (133, n=136-145mmol/L), hyperglycemia up to 532mg/dL and lithium levels werewithin normal limits (n=0.5-1.5 mmol/L). Urine drug screen was positive for cocaine. A CT scanof the head was negative. His myxedema score was diagnostic (>60). The patient wasdiagnosed with myxedema coma and admitted to the ICU. Patient was treated with IV LT4 400mcg, LT3 10mcg and hydrocortisone 100mg and started onIV LT4 100mcg daily, LT3 2.5mcg daily and hydrocortisone 100mg Q8 hours. There was wideglycemic variation from 46-532 mg/dL on POCT. The patient improved clinically, with resolutionof lethargy, confusion, fatigue, improved appetite, and improved lab work of FT3 2.30 (n=2.28-3.96pg/mL), FT4 at 0.76 (n=0.50-1.26ng/dL) and was downgraded from the ICU. On hospitalday four, he was transitioned to oral levothyroxine and discharged home. Conclusion: It is important to diagnose early and promptly manage decompensatedhypothyroidism in the setting of other comorbidities such as hyperglycemia in diabetes andpolysubstance abuse. The cocaine in the system may cause tachypnea and tachycardia. Manyconditions may have altered mental status, but with a history of hypothyroidism, Myxedemacoma should be on the differential due to its high mortality rate.

scholarly journals Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
T. M. Skipina ◽  
S. Macbeth ◽  
E. L. Cummer ◽  
O. L. Wells ◽  
S. Kalathoor
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Mental Status ◽  
Rare Case ◽  
Liver Function Tests ◽  
Altered Mental Status ◽  
Potassium Citrate ◽  
Metabolic Encephalopathy ◽  
History Of ◽  
Normal Urine

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

scholarly journals Assessment of the Primary and Intermediate School Staffs’ Knowledge, Attitude and Practice on Care of Children with Type 1 Diabetes at School, Al-Jouf, Saudi Arabia

2017 ◽  
Vol 12 (1) ◽  
pp. 33 ◽  
Author(s):  
Al Duraywish A A ◽  
Abdelsalam M Nail
Keyword(s):  
Type 1 Diabetes ◽  
Saudi Arabia ◽  
Diabetes Care ◽  
Primary Schools ◽  
Training Programs ◽  
School Nurse ◽  
Close Monitoring ◽  
School Teachers ◽  
Intermediate Schools

<p><strong>Background:</strong> Children with diabetes type 1 (T1DM) need close monitoring for their blood glucose, food intake, insulin therapy and physical activity during school hours in order to guard against the development of acute and long-term complications.</p><p><strong>Objectives: </strong>To evaluate the current situation of management of T1DM in primary and intermediate schools children through assessment of the working staffs' attitude, knowledge and practice at Al-Jouf, Saudi Arabia. <strong></strong></p><p><strong>Materials and Methods: </strong>This descriptive cross-sectional study enrolled consented voluntarily participating working staffs from primary and intermediate schools in Al-Jouf region, Saudia Arabia. A questionnaire (included 23 questions) testing knowledge, attitudes and practice regarding T1DM and care of diabetic children was used.</p><p><strong>Results:</strong> 744 teachers were studied (62.1% females) where58.1%of them were working in primary schools. Of all, 69% were class teachers, 20.4% administrators, 8.6% school counselors, and 2% physical education teachers.75.4% of the participants had adequate general knowledge about diabetes. Only 43.78% of the respondents had specific knowledge about diabetes in the school and teachers with a family diabetic patient showed higher knowledge about diabetes vs. their counterparts. Only 16.0%of the participants reported that their schools have trained personnel in diabetes. Large proportion of study teachers' (94%) was willing to join a training program for care of diabetic students. Of the total group of teachers, 665 support recruitment of a school nurse. <strong></strong></p><p><strong>Conclusion:</strong> Diabetes care training programs for school teachers and staffs, availability of school nurses and instigating collaboration between the diabetic center and the school is essential for safety of such diabetes student patients in the schools.</p><p><strong>Keywords:</strong> Type 1 Diabetes mellitus, School teachers, Training programs, Diabetes care, Knowledge about diabetes, School nurse, Diabetes care at the school.</p>

Frequency, clinical characteristics, biochemical findings and outcomes of DKA at the onset of type-1 DM in young children and adolescents living in a developing country – an experience from a pediatric emergency department

2019 ◽  
Vol 32 (2) ◽  
pp. 115-119 ◽  
Author(s):  
Amna Jawaid ◽  
Arjumand Sohaila ◽  
Nadia Mohammad ◽  
Unaib Rabbani
Keyword(s):  
Diabetes Mellitus ◽  
Emergency Department ◽  
Developing Countries ◽  
Type 1 Diabetes ◽  
Mortality Rate ◽  
Children And Adolescents ◽  
Diabetic Ketoacidosis ◽  
Clinical Characteristics ◽  
Incidence And Mortality

Abstract Background As per the International Society for Pediatrics and Adolescent Diabetes (ISPAD) census, diabetic ketoacidosis (DKA) is the most frequent cause of diabetes-related death. In developing countries, DKA-related mortality rate ranges from 6% to 24% (Onyiriuka AN, Ifebi E. Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47) in contrast to 0.15%–0.31% in the Western world (Poovazhagi V. Risk factors for mortality in children with diabetic ketoacidosis from developing countries. World J Diabetes 2014;5:932–93.). In developing countries like Pakistan, the situation is more perplexing owing to uncertain or under-reported statistics about the spectrum of the disease and its prevalence, coupled with limited access to medical care and experts as well as less awareness. These limitations restrict our ability to develop interventions that are patient-centered. Our main objective was to determine the severity, clinical features, bio-chemical findings and outcomes of DKA in children aged 1 month to 16 years. Subjects and methods This retrospective study included the analysis of medical and laboratory records from patients’ medical charts and the electronic database of all children aged 1 month to 16 years with newly diagnosed type-1 diabetes mellitus (T1DM) complicated with ketoacidosis, who presented to the emergency department (ED) at the Aga Khan University Hospital (AKUH), between January 2009 and December 2014. Results Diabetes mellitus complicated with DKA was the predominant diagnosis (n=113 [75.83%]) among endocrine diseases in children visiting the ED. Our study witnessed an increase in the incidence of DKA particularly after 5 years of age, with more severity in females. In our study, the mortality rate was 3.4%. Conclusions Considering the high incidence and mortality rate, it is emphasized that DKA should be considered in differential diagnosis. An awareness campaign for both general pediatricians and physicians as well as for the public is needed for better outcomes.

scholarly journals Euglycemic Diabetic Ketoacidosis in Type 1 Diabetes on Insulin Pump, with Acute Appendicitis: A Case Report

2021 ◽  
Vol 5 (3) ◽  
pp. 296-298
Author(s):  
Brian Thompson ◽  
Anthony Kitchen
Keyword(s):  
Type 1 Diabetes ◽  
Case Report ◽  
Acute Appendicitis ◽  
Diabetic Ketoacidosis ◽  
Insulin Pump ◽  
Point Of Care ◽  
Altered Mental Status ◽  
History Of ◽  
Euglycemic Diabetic Ketoacidosis

Introduction: Recently, euglycemic diabetic ketoacidosis has been an increasing topic of discussion within emergency medicine literature. Euglycemic diabetic ketoacidosis can easily be missed, as a normal point-of-care glucose often mistakenly precludes the work-up of diabetic ketoacidosis. Case Report: A 16-year-old female with a past medical history of type 1 diabetes presented to the emergency department with altered mental status, vomiting, and abdominal pain. She was diagnosed with euglycemic diabetic ketoacidosis. Conclusion: Reported cases of euglycemic diabetic ketoacidosis are most frequently attributed to sodium glucose cotransporter-2 inhibitors, but other potential causes have been discussed in the literature. In this patient, a starvation state with continued insulin use in the setting of acute appendicitis led to her condition.

scholarly journals Early onset type 1 diabetes mellitus in an infant during COVID-19 pandemic: case report

2021 ◽  
Vol 9 (10) ◽  
pp. 3189
Author(s):  
Made Yuliantari Dwi Astiti ◽  
Putu Harrista Indra Pramana ◽  
I. Wayan Bikin Suryawan
Keyword(s):  
Diabetes Mellitus ◽  
Type 1 Diabetes ◽  
Blood Glucose ◽  
Blood Glucose Level ◽  
Type 1 Diabetes Mellitus ◽  
Glucose Level ◽  
Early Onset ◽  
White Blood Cells ◽  
Close Monitoring

Type 1 diabetes mellitus (T1DM) is an endocrine disorder, marked by elevated blood glucose level caused by autoimmune process destroying the β-cells of the pancreas which mostly affects children. It is an often-overlooked condition, with low awareness among clinicians and parents alike which led to late diagnosis and patients often presenting with acute complications. Often triggered by a viral infection, here we presented an interesting case of early onset T1DM presenting with Diabetic ketoacidosis (DKA) during a COVID-19 pandemic. A female infant, aged 1 years and 2 days old, presented with dyspnea and fever. Physical examination was otherwise normal, without any rhonchi or wheezing found during pulmonary auscultation. Nasopharyngeal swab and SARS-CoV-2 antigen test was found negative. Laboratory workup found random blood glucose level of 577 mg/dl accompanied by acidosis and ketonuria. The patient also had elevated white blood cells and platelet counts. She was admitted for treatment in the Pediatric intensive care unit (PICU) with therapeutic regiments consisting of slow intravenous insulin infusion, potassium chloride intravenous fluid, antibiotics, and antipyretics. Close monitoring of blood glucose ensues and the patient was treated for 5 days followed by outpatient therapy with mixed insulin treatment twice per day. This case was interesting as T1DM usually manifested in older children with median age of diagnosis ranging from 8 to 13 years old, depending on population. T1DM diagnosed in children younger than 6 years old are classified early onset and it is especially rare to found in infants. Although the patient tested negative for SARS-CoV-2 antigen, the onset of the case coincides with a recent surge of cases locally. It meant that we cannot rule out possibility of prior unknown exposure or infection which may precipitate the condition.

scholarly journals Clinical Characteristics of Coronavirus Disease 2019 (COVID-19) among Patients at a Movement Disorders Center

Geriatrics ◽  
2020 ◽  
Vol 5 (3) ◽  
pp. 54
Author(s):  
Joy Antonelle de Marcaida ◽  
Jeffrey Lahrmann ◽  
Duarte Machado ◽  
Lawrence Bluth ◽  
Michelle Dagostine ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Mental Status ◽  
Movement Disorders ◽  
Clinical Characteristics ◽  
Altered Mental Status ◽  
Atypical Parkinsonism ◽  
Health Records ◽  
Telephone Interviews ◽  
Presenting Symptoms ◽  
Idiopathic Parkinson Disease

It is not established whether SARS-CoV-2 (COVID-19) patients with movement disorders, are at greater risk for more serious outcomes than the larger COVID-19 population beyond the susceptibility associated with greater age. We reviewed electronic health records and conducted telephone interviews to collect the demographics and clinical outcomes of patients seen at our Movement Disorders Center who tested positive for COVID-19 from 8 March 2020 through 6 June 2020. Thirty-six patients were identified, 23 men and 13 women, median age of 74.5 years. They primarily carried diagnoses of idiopathic Parkinson disease (n = 22; 61%) and atypical parkinsonism (n = 7; 19%) with the balance having other diagnoses. Twenty-seven patients (75%) exhibited alteration in mental status and fifteen (42%) had abnormalities of movement as common manifestations of COVID-19; in 61% and 31%, respectively, these were the presenting symptoms of the disease. Sixty-seven percent of patients in our cohort required hospitalization, and the mortality rate was 36%. These data demonstrate that in patients with movement disorders, the likelihood of hospitalization and death after contracting COVID-19 was greater than in the general population. Patients with movement disorders frequently presented with altered mental status, generalized weakness, or worsening mobility but not anosmia.

scholarly journals Effect of duration and burden of microvascular complications on mortality rate in type 1 diabetes: an observational clinical cohort study

Diabetologia ◽  
2019 ◽  
Vol 62 (4) ◽  
pp. 633-643 ◽  
Author(s):  
Lasse Bjerg ◽  
Adam Hulman ◽  
Bendix Carstensen ◽  
Morten Charles ◽  
Daniel R. Witte ◽  
...  
Keyword(s):  
Type 1 Diabetes ◽  
Cohort Study ◽  
Mortality Rate ◽  
Microvascular Complications ◽  
Clinical Cohort

scholarly journals Valproic Acid and Topiramate Induced Hyperammonemic Encephalopathy in a Patient With Normal Serum Carnitine

2013 ◽  
Vol 18 (2) ◽  
pp. 128-136 ◽  
Author(s):  
Martha G. Blackford ◽  
Stephanie T. Do ◽  
Thomas C. Enlow ◽  
Michael D. Reed
Keyword(s):  
Valproic Acid ◽  
Mental Status ◽  
Pediatric Intensive Care ◽  
Altered Mental Status ◽  
Ammonia Concentration ◽  
Normal Serum ◽  
Urine Drug Screen ◽  
Blood Ammonia ◽  
Persistent Symptoms ◽  
Hyperammonemic Encephalopathy

A 17-year-old female developed hyperammonemic encephalopathy 2 weeks after valproic acid (VPA), 500 mg twice a day, was added to her regimen of topiramate (TPM), 200 mg twice a day. She presented to the emergency department (ED) with altered mental status, hypotension, bradycardia, and lethargy. Laboratory analysis showed mild non-anion gap hyperchloremic acidosis, serum VPA concentration of 86 mg/L, and urine drug screen result that was positive for marijuana. She was admitted to the pediatric intensive care unit for persistent symptoms, prolonged QTc, and medical history. Blood ammonia concentrations were obtained because of her persistent altered mental status, initially 94 μmol/L and a peak of 252 μmol/L. A serum carnitine profile was obtained at the time of hyperammonemia and was found to be normal (results were available postdischarge). VPA and TPM were discontinued on day 1 and day 2, respectively, as the patient's blood ammonia concentration remained elevated. On day 3, her mental status had returned to baseline, and blood ammonia concentrations trended downward; by day 4 her blood ammonia concentration was 23 μmol/L. VPA has been associated with numerous side effects including hyperammonemia and encephalopathy. Recently, drug interactions with TPM and VPA have been reported; however, serum carnitine concentrations have not been available. We discuss the possible mechanisms that VPA and TPM may affect serum ammonia and carnitine concentrations and the use of levocarnitine for patients or treating toxicity.

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