Case Study: Diabetic Ketoacidosis in Type 2 Diabetes: “Look Under the Sheets”

Abstract

Presentation C.S., a previously healthy 26-year-old Cantonese woman, presented with 6 days of nausea, vomiting, occasional fevers, and nonspecific abdominal pain that progressed to myalgias, polyuria, polydipsia, fatigue, and delirium. She had been asleep in bed for many hours preceding admission. Her only medication was an oral contraceptive, and she did not use herbals or alcohol. Her father had type 2 diabetes. In the emergency room, she was mildly delirious, hyperventilating, afebrile, and dehydrated. She weighed 133 lb, her pulse was 110 bpm, and her blood pressure was 102/62 mmHg. The physical exam was otherwise normal. Urinalysis revealed 4+ glucose and ketones, large blood without red blood cells, and no infection. The urine was tea-colored. Plasma glucose was 809 mg/dl, betahydroxybutyrate 6.9 mmol/l, lactate 3.2 mmol/l, sodium 126 mmol/l, potassium 4.9 mmol/l, creatinine 2.2 mg/dl, carbon dioxide 9 mmol/l, leukocytes 24,800/ml, arterial pH 7.06, and partial pressure of arterial carbon dioxide (PaCO 2) was 15 mmHg. Toxicology screen was negative, phosphate was 3.0 mmol/l, alanine aminotransferase was 299 IU/l, and aspartate aminotransferase was 782 IU/l, with normal bilirubin and alkaline phosphatase levels. Creatine kinase (CK) was 46,305 IU/l. Troponin I peaked at 5.8 ng/ml, but C.S. reported no chest pain, and electrocardiogram showed only sinus tachycardia. Islet cell, insulin, and glutamic acid decarboxylase antibodies were negative. Her hemoglobin A 1c was 6.7%.

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Diabetes mellitus – an overview

“…Excess ketones in the blood lead to a condition called ketoacidosis, which can be lifethreatening if left untreated. Ketoacidosis is more common in type 1 diabetics [54].…”