scholarly journals Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Associated With COVID 19

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A372-A373
Author(s):  
José Martín Alanís Naranjo ◽  
Eduardo Federico Hammeken Larrondo ◽  
María Guadalupe Silva Arroyo
Keyword(s):  
Mechanical Ventilation ◽  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Blood Glucose Control ◽  
Disease Patient ◽  
Case Series ◽  
Arterial Blood ◽  
Hyperosmolar Hyperglycemic State ◽  
History Of ◽  
D Dimer

Abstract Background: Cases of patients with combined DKA and HHS associated to COVID-19 are scarce but showed Hispanics patients tended to be associated with higher mortality. Clinical Case: A 51-year-old Mexican man with past medical history of T2DM presented to our hospital with 1-week history of fever, dyspnea, polydipsia, and nausea. Initial vital signs were notable for fever (axillary temperature 39°C) and low oxygen saturation (90% on room air). His examination was notable for a BMI of 31.2 kg/m2. Blood tests showed hyperglycemia (663 mg/dl, n 70–100 mg/dL), hypernatremia (146 mEq/L, n 135–145 mEq/L), hyperchloremia (113 mEq/L, n 95–110 mEq/L), elevated C-Reactive Protein [CRP] (18.7 mg/dl, n < 0.7 mg/dl), elevated lactate dehydrogenase [LDH] (672 U/L, n 100–170 U/L), high D-dimer (3420 ng/ml, n <400 ng/ml), elevated WBC count (13,200 cell/mm3, n 4600–10200 cells/mm3), high neutrophil count (11300 cells/mm3, n 2000–6900 cells/mm3) and low lymphocyte count (200 cells/mm3, n 600–3400 cells/mm3). Arterial blood gas analysis showed metabolic acidosis (pH 7.2 [n 7.35–7.45], bicarbonate 8mmol/L [22–28 mmol/L], anion gap 23.5 [8–16]) with ketones (100 mg/dl, n <5 mg/dl) in the urine analysis. Calculated serum osmolarity resulted of 328 mOsm/kg (n 278–305 mOsm/kg). Electrocardiogram showed no alterations. Chest X-ray revealed bilateral ground-glass opacities with bilateral infiltrates. Blood and urine cultures were negative. The patient tested positive for SARS-CoV-2. Intravenous fluids, insulin infusion with ceftriaxone i.v. (2 g daily) and clarithromycin p.o. (1 g daily) were initiated but did not result in clinical improvement, continuing with fever, hyperglycemia, metabolic acidosis and worsening of respiratory status. At first day of hospitalization, he presented acute respiratory distress syndrome and was intubated and sedated. He developed multi-organ failure and expired after 3 days of mechanical ventilation. Conclusion: DM is a predisposing factor leading to severe COVID-19 disease. Patient showed similar features reported in cases who died of combined DKA and HHS associated with COVID-19: male, Hispanic, poor blood glucose control, mechanical ventilation, elevated CRP with high LDH and D-dimer. In this patient, obesity was an additional feature that led to severe COVID- 19. Reference: Hoe Chan K, Thimmareddygari D, Ramahi A, Atallah L, Baranetsky NG, Slim J (2020) Clinical characteristics and outcome in patients with combined diabetic ketoacidosis and hyperosmolar hyperglycemic state associated with COVID-19: a retrospective, hospital-based observational case series. Diabetes Res Clin Pract 166:108279

Diabetic ketoacidosis, hyperuricemia and encephalopathy intractable to regular-dose insulin

2017 ◽  
Vol 30 (12) ◽  
Author(s):  
Jillian Gregory ◽  
Sonali Basu
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Work Of Breathing ◽  
Altered Mental Status ◽  
Inborn Errors ◽  
Case Presentation ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
History Of

AbstractBackground:Diabetic ketoacidosis (DKA) in children less than 1 year of age is a rare occurrence. Typical presentation includes a prodrome of weight loss and polyuria with subsequent presentation to medical care when acidosis becomes symptomatic.Case presentation:We describe an unusual case of a previously healthy infant with a 3 days’ history of constipation, presenting acutely with abdominal pain, lethargy, and dehydration. On initial evaluation, our patient had profound encephalopathy, with marked tachypnea and work of breathing. Arterial blood gas revealed a pH of 6.9, pCO2 of 20 and a bicarbonate level of <5. There was profound leukocytosis (WBC 77 K/μL), hyperuricemia (uric acid 15.9 mg/dL), and evidence of pre-renal azotemia [blood urea nitrogen (BUN) 54, Cr 0.82]. Blood glucose was >700 mg/dL. Despite fluid resuscitation and insulin infusion of 0.1 unit/kg/h, which are the mainstays of therapy for DKA, her severe metabolic acidosis and altered mental status did not improve. Differential diagnosis for her metabolic derangements included inborn errors of metabolism, insulin receptor defects, toxic ingestions, and septic shock secondary to an underlying oncologic or intra-abdominal process. The patient was treated with broad spectrum antibiotics and rasburicase. She continued to have significant shock for the first 30 h of her hospital stay, requiring moderate vasoactive support. Due to her refractory acidosis and persistent hyperglycemia, insulin infusion was increased to 0.15 units/kg/h. A hemoglobin AConclusions:Metabolic acidosis in an infant requires a broad differential. Rasburicase should be considered in hyperuricemia and DKA.

scholarly journals 63. Prognosis of COVID-19 Patients with Diabetic Ketoacidosis with or Without Hyperosmolar Hyperglycemic State

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S163-S163
Author(s):  
Kok Hoe Chan ◽  
Divya Thimmareddygari ◽  
Amr Ramahi ◽  
Liana Atallah ◽  
Jihad Slim
Keyword(s):  
Diabetes Mellitus ◽  
Diabetic Ketoacidosis ◽  
Case Series ◽  
Plasma Osmolality ◽  
Retrospective Case ◽  
Female Ratio ◽  
Hyperosmolar Hyperglycemic State ◽  
History Of ◽  
Male To Female

Abstract Background One of the risk factors for poor outcome with SARS-CoV-2 infection is diabetes mellitus; diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most serious complications of diabetes mellitus. We aimed to explore the clinical characteristics and outcomes of COVID-19 patients presenting with isolated DKA or combined DKA/HHS to our institution. Methods A retrospective, hospital based observation case series was performed on patients with SARS-CoV-2 admitted to Intensive Care Unit between 03/20/20 and 04/20/20. Inclusion criteria were: 1) Blood Glucose &gt;250mg/dL; 2) Serum bicarbonate &lt; 18 mmol/L; 3) Anion Gap &gt;10; 4) serum pH &lt; 7.3; 4) ketonemia or ketonuria; and 5) positive SARS-CoV-2 RT-PCR. Hyperosmolality, on the other hand, was defined as an effective/calculated plasma osmolality &gt;304 mOsm/kg. Results A total of 87 patients with COVID-19 were admitted to the ICU during the study period, 12 of them had either isolated DKA or DKA/HHS. Baseline demographics, lab values and outcome are summarized in Table 1. Six of the patients had isolated DKA and six had combined DKA and HHS. The median age for the patient was 49.5 years old (range from 19 to 62 years old). The male to female ratio was 5:1. Of the 12 patients, 10 patients (83%) had a history of DM, nine were type 2 and only one type 1; two patients were newly diagnosed DM, presenting as DKA, presumptively precipitated by COVID-19. Five patients (42%) had a BMI &gt;30 kg/m2. As for ethnicity; seven were Hispanic (59%), four African American (33%), and one Caucasian (8%). Patients with combined DKA/HHS, higher BMI, higher HbA1c, severe acidosis tended to have higher mortality. The striking feature was that isolated DKA or combined DKA/HHS was the initial presentation for COVID-19 for most of the cases. Table 1: Demographic characteristic, inflammatory markers and outcome. Conclusion Our observational retrospective case series reinforces the need to watch for new onset DM and monitor blood sugar closely in those with known diabetes mellitus during SARS-CoV-2 infection, in order to avoid such serious complications as DKA and HHS. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

scholarly journals A Rare Case of Pseudohypoaldosteronism Type II or Gordon Syndrome

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A105-A105
Author(s):  
F N U Manas ◽  
Shobha Mandal ◽  
Barbara L Mols-Kowalczewski
Keyword(s):  
Blood Pressure ◽  
Metabolic Acidosis ◽  
Family History ◽  
Rare Case ◽  
Plasma Renin ◽  
Type Ii ◽  
Arterial Blood ◽  
Pseudohypoaldosteronism Type Ii ◽  
History Of ◽  
Pseudohypoaldosteronism Type

Abstract Introduction: Pseudohypoaldosteronism type II (PHA II) or Gordon Syndrome is a rare, autosomally inherited disease with unknown prevalence. It is caused by mutations in the WNK1, WNK4, CUL3, or KLHL3 gene. It is characterized by hypertension, hyperkalemia, hyperchloremic metabolic acidosis and low plasma aldosterone levels, but otherwise normal kidney function. The age of onset of PHA2 is variable, ranging from infancy or childhood to adolescence and adultdood. The electrolyte and blood pressure abnormalities of PHA II is often managed with salt restriction and hydrochlorthiazide (HCTZ). Here we report a rare case of Pseudohypoaldosteronism type II in an adolescent patient. Case Presentation: A 16-yo female with past medical history of asthma and anemia presented to the emergency department with acute severe abdominal/suprapubic pain, associated with diaphoresis, non bloody diarrhea and non bilious non bloody vomiting. The patient also reported daily headaches relieved with Tylenol. In the ED, she was found to be hypertensive at 190/118 mmHg. Blood count showed mild anemia but normal white count and platelets. Comprehensive metabolic panel showed sodium 140, potassium 6.6, chloride 115, bicarbonate 16, creatinine 0.5, and normal liver enzymes. Urine electrolytes were as follows: sodium 189, potassium 20.8 and chloride 140. Arterial Blood Gas ahowed pH of 7.32. Plasma renin activity was low normal at 0.34 and aldosterone level was 2. CT scan of abdomen and pelvis was unremarkable. The blood work was consistent with pseudohypoaldosteronism type II or Gordon syndrome. The patient was adopted so there was no family history. She was started on hydrochlorothiazide. Later, she developed severe itching reaction with hydrochlorthiazide. She is currently being treated with Indapamide, with well controlled blood pressure and normal electrolytes. Conclusion: Pseudohypoaldosteronism type II or Gordon’s Syndrome is a rare disease, with usually autosomal dominant inheritance, with no specific diagnostic criteria for diagnosis. It should be suspected in adolescent or adult patients with hyperkalemia with normal glomerular filtartion, accompanied by hypertension (can be absent), metabolic acidosis, hyperchloremia, decreased plasma renin, relatively suppressed aldosteronism and family history of similar findings.

scholarly journals Acute Pancreatitis Induced by Diabetic Ketoacidosis with Major Hypertriglyceridemia: Report of Four Cases

2020 ◽  
Vol 2020 ◽  
pp. 1-4
Author(s):  
Karama Bouchaala ◽  
Mabrouk Bahloul ◽  
Sabrine Bradii ◽  
Hela Kallel ◽  
Kamilia Chtara ◽  
...  
Keyword(s):  
Acute Pancreatitis ◽  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Multiorgan Failure ◽  
Case Series ◽  
Good Health ◽  
High Serum ◽  
Undiagnosed Diabetes ◽  
Health State ◽  
Lipid Panel

Acute pancreatitis (AP) is a real clinical challenge. Acute pancreatitis remains a common cause of emergency department consultations and a major cause for hospitalization. Gallstones and drinking a lot of alcohol are the most frequent causes of AP. Moreover, AP can be induced by diabetic ketoacidosis (DKA) complicated by hypertriglyceridemia. We report 4 cases of DKA with hypertriglyceridemia complicated by AP in previously undiagnosed diabetes patients. All of our patients presented to the emergency ward with abdominal pain. Their physical exam showed epigastric tenderness. An abdominal CT scan was performed for each patient, showing an AP grade E. Laboratory samples showed high serum glucose levels. They had metabolic acidosis with elevated anion gap. They had high lipasemia and amylasemia. Their lipid panel was disturbed with a high level of cholesterol (from 12.8 mmol/l to 33 mmol/l) and triglyceridemia (from 53 to 133 mmol/l). Our patients were admitted into our ICU where they received fluid resuscitation and intravenous insulin, and their triglycerides rates decreased gradually. Two patients recovered to a good health state, and the two others developed septic shock, requiring the use of large-spectrum antibiotics, and acute kidney injury (AKI) with refractory metabolic acidosis, requiring hemodialysis. Despite the intensive treatment, they developed an unrecoverable multiorgan failure. Through our case series, we aim to highlight the importance of making an early diagnosis, which can be difficult in some situations due to overlapping signs; however, it is crucial for a good recovery. A good understanding of the pathway of hypoinsulinemic states causing hypertriglyceridemia then AP is important because it is the key to best management.

Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor

2021 ◽  
Vol 6 (1) ◽  
Author(s):  
Lavrynenko O ◽  
◽  
Santos H ◽  
Garza A ◽  
Qazi R ◽  
...  
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Glucose Transporter ◽  
Sglt2 Inhibitor ◽  
Anion Gap ◽  
Laboratory Evaluation ◽  
Intravenous Insulin ◽  
Glucose Transporter 2 ◽  
Life Threatening ◽  
History Of

Diabetic Ketoacidosis (DKA) is a life - threatening complication and must be diagnosed and treated promptly and aggressively. The classic triad of DKA is hyperglycemia (Blood Glucose (BG) >250mg/dl; anion gap metabolic acidosis (pH <7.30 and bicarbonate <18mEq/L); and ketonemia. With Food and Drug Administration (FDA) approval of the sodium - glucose transporter 2 inhibitors (SGLT2i), DKA can occur with BG levels below 200mg/dl and has been defined as Euglycemic DKA (EuDKA). Due to the absence of hyperglycemia, the diagnosis of EuDKA is challenging and often delayed. This 60-year-old diabetic male, treated with Empagliflozin and pioglitazone, presented with diarrhea and abdominal pain, which started 20 days ago. He was admitted with dehydration and diagnosis of colitis. On admission laboratory evaluation revealed metabolic acidosis with elevated anion gap of 18mEq/L, bicarbonate of 19mEq/L, and BG of 146mg/dL. There was no history of ingestion of alcohol, salicylates, methanol, ethylene glycol and nothing to suggest lactic acidosis. The plasma creatinine was 0.79mg/dl. On the following day, he developed an increase in the anion gap to 22mEq/L and further decrease in bicarbonate to 13mEq/L, and serum ketones were detected. The patient was treated for EuDKA in ICU with intravenous insulin, dextrose (to prevent hypoglycemia), and normal saline with resolution of his symptoms and EuDKA in 3 days. With the widespread use of SGLT2i, physicians need to have a high suspicion of EuDKA in patients who present with an unexplained anion gap acidosis without or only modest elevation in BG concentration.

Presentation of mixed diabetic ketoacidosis and metabolic acidosis due to ileal neobladder reconstruction

2021 ◽  
Vol 14 (2) ◽  
pp. e223668
Author(s):  
Dileep Kumar ◽  
Muhammad Zubair Nasim ◽  
Bilal Ahmad Shoukat ◽  
Syed Shabahat Ali Shah
Keyword(s):  
Diabetes Mellitus ◽  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Plasma Glucose ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Anion Gap ◽  
Metabolic Complications ◽  
Ileal Neobladder ◽  
History Of

Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes mellitus. It is characterised by the biochemical triad of hyperglycaemia, ketonemia/ketonuria, and an increased anion gap metabolic acidosis. In this case, a 40-year-old male patient presented to the emergency department, with vomiting, nausea, polydipsia, polyuria and weight loss. He was found to have an elevated plasma glucose, despite having no known history of diabetes mellitus. His medical history was significant for spina bifida and ileal neobladder reconstruction. The plasma glucose level was 38 mmol/L. Blood gas analysis showed normal anion gap metabolic acidosis with high chloride and low bicarbonate. His plasma ketone level was 4.5 mmol/L. No significant reason for hyperchloraemia was identified. On initiation of DKA regimen, his condition improved and serum ketones normalised. Due to persistent hyperchloraemic metabolic acidosis, bicarbonate infusion was administered and his metabolic acidosis resolved.

The Ventilatory Response in Diabetic Ketoacidosis

1974 ◽  
Vol 46 (4) ◽  
pp. 539-549 ◽  
Author(s):  
M. Fulop ◽  
N. Dreyer ◽  
H. Tannenbaum
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Ventilatory Response ◽  
Hydrogen Ion ◽  
Inverse Relation ◽  
Bicarbonate Concentration ◽  
Plasma Bicarbonate ◽  
Arterial Blood ◽  
Blood Ph ◽  
Ion Activity

1. Previous studies of the ventilatory response to metabolic acidosis have usually considered only patients with arterial blood pH above 7·10. To define the response during more severe acidaemia, arterial CO2 tension and pH were measured in fifty-three episodes of diabetic ketoacidosis, including twenty-four with pH below 7·10, and ten with pH below 7·00. 2. The relation between arterial CO2 tension, and both blood pH and plasma bicarbonate concentration, in these cases with generally severe metabolic acidaemia (mean pH 7·12 ± SD 0·13), was very similar to the relations between those variables found by others in patients with less severe acidaemia, such as that due to renal failure. 3. As arterial blood hydrogen ion activity increased, arterial CO2 tension decreased inversely, reflecting well-sustained hyperventilation, even during profound acidaemia. 4. The inverse relation between arterial CO2 tension and hydrogen ion activity suggests that during metabolic acidosis, alveolar ventilation increases in direct proportion to the increased blood hydrogen ion activity.

scholarly journals COVID-19 and Combined Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Coma: Report of 11 Cases

2021 ◽  
Vol 9 ◽  
pp. 232470962110212
Author(s):  
Balraj Singh ◽  
Parminder Kaur ◽  
Nicole Majachani ◽  
Prem Patel ◽  
Ro-Jay Romor Reid ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Diabetic Ketoacidosis ◽  
Case Series ◽  
Kidney Injury ◽  
Altered Mental Status ◽  
Metabolic Complications ◽  
Poor Prognostic Factor ◽  
Vulnerable Patient ◽  
Hyperglycemic Hyperosmolar Nonketotic Coma ◽  
Type 1 Dm

We report 11 cases of combined diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNK) in coronavirus 2019 patients who presented to our institution in New Jersey, USA. The median age was 47 years (range 12-88 years). Out of the 11 patients, 7 were male and 4 were female. Out of 11 patients, 8 had type 2 diabetes mellitus (DM), 2 had undiagnosed DM, and 1 had type 1 DM. Presenting complaints included altered mental status, weakness, shortness of breath, cough, fever, vomiting, abdominal pain, chest pain, and foot pain. Out of 11 patients, pneumonia was diagnosed at presentation in 8 patients, while in 3 patients, chest X-ray was clear. Median value of initial glucose on presentation was 974 mg/dL (range 549-1556 mg/dL), and hemoglobin A1c on presentation was 13.8%. The median value of anion gap was 34 mEq/L. Out of the 11 patients, ketonemia was moderate in 6 patients, large in 3, and small in 2 patients. Acute kidney injury (AKI) occurred in 9 patients and 2 patients required renal replacement therapy. Out of the 11 patients, 6 required mechanical ventilation and 7 patients died. All the 6 patients requiring mechanical ventilation died. Our case series shows COVID-19 infection can precipitate acute metabolic complications in known DM patients or as first manifestation in undiagnosed DM patients. Patients can present with DKA/HHNK symptoms and/or respiratory symptoms. Mechanical ventilation is a poor prognostic factor. Further studies are needed to characterize prognostic factors associated with mortality in this vulnerable patient population.

scholarly journals DIABETIC KETOACIDOSIS WITH LOWER-THAN-ANTICIPATED GLUCOSE LEVELS WITH SGLT-2 INHIBITOR CANAGLIFLOZIN: A CASE REPORT AND REVIEW OF THE LITERATURE.

2020 ◽  
pp. 1-2
Author(s):  
Ajay Budhwar ◽  
Parul Malhotra
Keyword(s):  
Case Report ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Sglt2 Inhibitor ◽  
Gas Analysis ◽  
Glucose Levels ◽  
Arterial Blood ◽  
History Of ◽  
Euglycemic Diabetic Ketoacidosis

We describe a case report of a patient who presented with euglycemic diabetic ketoacidosis (euDKA), six days after starting treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitor, Canagliflozin. ‘Euglycemic diabetic ketoacidosis’ or ‘DKA with lower-than-anticipated glucose levels’ (as recommended by AACE/ACE) is a rare, challenging and easy to miss the diagnosis A 41-year-old male with a history of type 2 Diabetes Mellitus presented with uncontrolled hyperglycemia. Canagliflozin (SGLT2 inhibitor) was added to his anti-diabetic regimen of Metformin and Sitagliptin. Six days later, he presented with symptoms of diabetic ketoacidosis with normal blood glucose of 131mg/dl. The patient was further investigated with arterial blood gas analysis and serum ketone studies, keeping in view of the potential of euglycemic diabetic ketoacidosis (euDKA) with SGLT2 inhibitor use. The clinical picture and lab values of the patient were consistent with diabetic ketoacidosis(DKA), although it is rare in type 2 DM. Blood glucose was in the normal range which could have delayed the diagnosis if the physician was not vigilant. If one had only focused on the blood glucose, then this potentially fatal condition could have been missed. However, when other causes of anion gap metabolic acidosis were excluded and the lab values of urine ketones, elevated beta-hydroxybutyrate, reduced bicarbonate, and normal lactate interpreted, it leads to the diagnosis of SGLT2 inhibitor-associated euglycemic DKA. We performed a literature review of this topic and discuss the history of euglycemic diabetic ketoacidosis, risk factors, pathophysiology, diagnosis, management, and prevention of SGLT2 inhibitor-induced euDKA.

Sign in / Sign up

Export Citation Format

Share Document