A Narrative Review on Diabetic Ketoacidosis in Children

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening complication in children with diabetes mellitus. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. This is based on the concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration. However, in recent years, new clinical studies suggest that there is no causal relationship between intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians.

OBJECTIVES

The purpose of this article is to provide a narrative review on the management of DKA.

METHODS

A PubMed search was performed with clinical queries using the key term "diabetic ketoacidosis". The search strategy included randomized controlled trials, clinical trials, meta-analyses, observational studies, guidelines, and reviews. The search was restricted to English literature and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines.

CONCLUSION

The management of DKA involves early recognition, accurate diagnosis, meticulous fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal function, and neurological status. There is still limited clinical evidence to support either a restrictive or permissive approach in the fluid management of paediatric DKA patients. Clinicians should exercise caution when applying different guidelines in their clinical practice, considering the specific circumstances of individual paediatric patients.

A Swedish national population-based study in 2014-2019

AIMS

The aim of the study was to estimate the effect of household relative poverty on the risk of diabetic ketoacidosis at diagnosis of children with type 1 diabetes using an international standard measurement of relative poverty.

METHODS

A national population-based retrospective study was conducted. The Swedish National Diabetes Register (NDR) was linked with data from Sweden's public statistical agency (Statistics Sweden). Children who were diagnosed with new-onset type 1 diabetes in the period of 2014-2019 were common identifiers. The definition of diabetic ketoacidosis was venous pH <7.30 or a serum bicarbonate level <18 mmol/L. The exposure variable was defined according to the standard definition of the persistent at-risk-of-poverty rate used by the statistical office of the European Union (Eurostat) and several other European public statistical agencies. Univariate and multi-variable analyses were used to calculate the effect of relative poverty on the risk of diabetic ketoacidosis.

RESULTS

Children from households with relative poverty had a 41% higher risk of diabetic ketoacidosis (1.41, CI 1.12-1.77, p = 0.004) and more than double the risk of severe diabetic ketoacidosis (pH <7.10) (RR 2.10, CI 1.35-3.25, p = 0.001), as compared to children from households without relative poverty.

CONCLUSIONS

Relative poverty significantly increases the risk of diabetic ketoacidosis at onset of type 1 diabetes in children, even in a high-income country with publicly reimbursed health care.

Utility of Polygenic Scores for Differentiating Diabetes Diagnosis Among Patients With Atypical Phenotypes of Diabetes

CONTEXT

Misclassification of diabetes type occurs in people with atypical presentations of type 1 diabetes (T1D) or type 2 diabetes (T2D). Although current clinical guidelines suggest clinical variables and treatment response as ways to help differentiate diabetes type, they remain insufficient for people with atypical presentations.

OBJECTIVE

This work aimed to assess the clinical utility of 2 polygenic scores (PGSs) in differentiating between T1D and T2D.

METHODS

Patients diagnosed with diabetes in the UK Biobank were studied (N = 41 787), including 464 (1%) and 15 923 (38%) who met the criteria for classic T1D and T2D, respectively, and 25 400 (61%) atypical diabetes. The validity of 2 published PGSs for T1D (PGST1D) and T2D (PGST2D) in differentiating classic T1D or T2D was assessed using C statistic. The utility of genetic probability for T1D based on PGSs (GenProb-T1D) was evaluated in atypical diabetes patients.

RESULTS

The joint performance of PGST1D and PGST2D for differentiating classic T1D or T2D was outstanding (C statistic = 0.91), significantly higher than that of PGST1D alone (0.88) and PGST2D alone (0.70), both P less than .001. Using an optimal cutoff of GenProb-T1D, 23% of patients with atypical diabetes had a higher probability of T1D and its validity was independently supported by clinical presentations that are characteristic of T1D.

CONCLUSION

PGST1D and PGST2D can be used to discriminate classic T1D and T2D and have potential clinical utility for differentiating these 2 types of diseases among patients with atypical diabetes.

A Case of Severe Lactation Ketoacidosis in a Nondiabetic Mother on a Ketogenic Diet

Lactation ketoacidosis is a rare yet severe metabolic emergency that has been reported in breastfeeding mothers. Reduced carbohydrate intake during breastfeeding has been reported as a common trigger for ketoacidosis. We report the case of a 31-year-old mother without diabetes who presented with life-threatening lactation ketoacidosis after following a ketogenic diet while exclusively breastfeeding her newborn baby. She was managed in the intensive care unit with dextrose and insulin infusion to reverse ketoacidosis. With prompt treatment, the patient's ketoacidosis resolved within 24 hours, and she was discharged well 3 days later. We further discuss the underlying increased metabolic demand in lactating women that puts them at risk of ketoacidosis, underlining the importance of early recognition of lactation ketoacidosis and nutritional education for lactating women.

Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors

Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.

Type 1 diabetes and low carbohydrate diets-Defining the degree of nutritional ketosis

AIMS

Adopting a low- or very low-carbohydrate (LCD or VLCD) diet in type 1 diabetes mellitus (T1D) is a controversial intervention. The main fear is that these diets may increase the risk of diabetic ketoacidosis. However, there is little data about the ketoacidosis risk and the level of physiological nutritional ketosis in individuals following these diets. We aimed to define the level of ketosis in those with T1D following carbohydrate restricted diets in a real-world observational study.

METHODS

Patients with T1D who had self-selected dietary carbohydrate restriction were enrolled from local clinics and were compared to those following an unrestricted regular carbohydrate control diet (RCCD). Participants completed a 3-day diary, documenting food intake, ketones, and blood/interstitial glucose concentrations.

RESULTS

Participants were divided into three groups according to mean carbohydrate intake: VLCD (<50 g carbohydrates/day) n = 6, LCD (50-130 g carbohydrates/day) n = 6, and RCCD (>130 g carbohydrates/day) n = 3. Mean beta-hydroxybutyrate (BOHB) concentrations were 1.2 mmol/l (SD 0.14), 0.3 mmol/l (SD 0.12) and 0.1mmol/l (SD 0.05) in the VLCD, LCD and RCCD groups, respectively (p = 0.02). Post hoc Dunn test demonstrated this reached statistical significance between the VLCD and RCCD groups (p = 0.02).

CONCLUSION

Carbohydrate restricted diets, in particular VLCDs, are associated with a higher BOHB level. However, the degree of ketosis seen is much lower than we expected, and significantly lower than the level typically associated with diabetic ketoacidosis. This may suggest the risk of ketoacidosis is lower than feared, although safety will need to be evaluated further in large scale randomised trials.

Evidence of increasing incidence of type 1 diabetes and ketoacidosis among children in the Republic of Srpska in period 2017-2022 with special focus on COVID-19 global pandemic years

Background and objectives

Primary focus of the research was to determine the incidence of type 1 diabetes mellitus in the period from 2017 to 2022, and whether COVID-19 had an impact on the increase in the number of newly diagnosed children with diabetes type 1 under the age of 15 in the Republic of Srpska (Bosnia and Herzegovina). In the period 2001-2016 the incidence of type 1 diabetes mellitus was 11/100,000, with an annual increasing rate of 14.2%.

Methods

Available data from pediatric endocrinology clinics, in the Republic of Srpska, on the number of newly diagnosed patients with diabetes mellitus in the period from January 1, 2017 until December 31, 2022 were used. A retrospective analysis was performed, and the capture-recapture method was used for the final assessment, and the obtained result corresponds to about 99% of the population.

Results

The total number of children in the group of 0-14 years of age diagnosed with type 1 diabetes mellitus in this period was 183, of which 96 (52.46%) were boys, and 87 (47.54%) were girls. The average age at which diabetes mellitus was diagnosed was 8.3 ± 3.9 years. Average incidence of diabetes in the period 2017-2022 was 19/100,000 (95% CI 13.1-25.0). The highest incidence was 28.7/100,000 in 2020, the first year of the global COVID-19 pandemic. Out of a total of 183 newly diagnosed cases in the period 2017-2022, 73 (39.9%) were diagnosed with ketoacidosis upon admission. The largest number of newly diagnosed children was recorded in the group of children aged 10-14 years.

Conclusion

In the last 6 years, there has been a significant increase in the incidence of type 1 diabetes mellitus in children under the age of 15. With an incidence of 19.4/100,000 in the Republic of Srpska, we entered the group of countries with high-risk for diabetes. Further steps must focus on the education of the entire society in order to recognize the symptoms of the disease in time and prevent the occurrence of ketoacidosis, which could significantly reduce the burden on health systems, especially in times of global pandemics, such as the COVID-19 pandemic.

Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt

The coronavirus disease (COVID-19) pandemic affected the management and follow-up of several chronic ailments, including pediatric type 1 diabetes mellitus (T1DM). Restricted access to healthcare and fear of contracting the virus during medical facility visits resulted in poor compliance, irregular follow-up visits, treatment, and delayed diagnosis of complications in pediatric diabetes such as diabetic ketoacidosis (DKA). As such, the incidence of complicated DKA in resource-limited settings is high due to delayed presentation, poor compliance with therapy, and associated comorbidities such as malnutrition and sepsis. The pandemic had only added to the woes. The increased surge in DKA, in the face of limited resources, prompted clinicians to find alternative solutions to manage these children effectively. In this narrative review, we discuss the key challenges faced globally while caring for children with T1DM and DKA during the COVID-19 pandemic, and the lessons learned thereof.

Rhino-Orbito-Cerebral Mucormycosis: A Challenging Case

Mucormycosis is a rare opportunistic fungal infection caused by Mucorales and associated with high mortality rates. Rhino-orbito-cerebral localization usually occurs in individuals with uncontrolled diabetes mellitus. We report the case of a 41-year-old male, with previously undiagnosed diabetes, who presented with unilateral facial extensive black eschar and signs of diabetic ketoacidosis. Cerebral magnetic resonance imaging showed left pansinusitis, left craniofacial edematous infiltrate, and left proptosis. A left internal temporal abscess was identified at an early pre-suppurative stage. Magnetic resonance angiography revealed total occlusion of the left intracranial internal carotid artery. A histopathological study of nasal mucosa biopsy suggested mucormycosis. According to the clinical presentation and the radiological and histopathological findings, rhino-orbito-cerebral mucormycosis was presumed. Culture of nasal, ocular, and skin lesion specimens grew Rhizomucor sp. and confirmed the diagnosis. The patient was treated with systemic liposomal amphotericin B. He died of multiple organ failure before surgical debridement was possible as he was in critical condition requiring stabilization before surgical treatment.

Combined lactic acidosis and ketoacidosis in a female diabetic patient with severe heart failure

SGLT2i are now recommended in a wide spectrum of indications including type 2 diabetes (T2DM), heart failure, and chronic kidney disease. This medication class is now available in combination with metformin, which is still a fundamental treatment in patients with T2DM. Despite excellent proven safety profile for both drugs, the expanding use of these agents in clinical practice may lead to an increased incidence of rare side effects, like metformin-associated lactic acidosis (MALA) and euglycemic diabetic ketoacidosis (EDKA), which can be life-threatening. A 58-year-old woman with T2DM and severe heart failure treated by metformin and empagliflozin developed progressive EDKA triggered by fasting that was also complicated by severe acute renal failure and MALA. She was successfully treated with intermittent hemodialysis. This case report highlights the importance of the recognition of rare, but very serious adverse effects due to combined metformin and SGLT2i therapy.

A sweet emergency due to bitter poisoning-A case report

Organophosphorus compounds (OPC) are major components of pesticides and nerve gas agents. Self-harm by ingestion of OPC pesticides is one of the common problems encountered in the emergency room (ER), especially in developing countries such as India. It is recognised by the World Health Organization (WHO) as the third most prevalent means of suicide. In addition to the cholinergic effects caused by these agents, they can induce metabolic dysregulations. We present a case of a 22-year-old male patient, without previous history of diabetes, who was brought to the ER in an unresponsive state with an HbA1c of 5%. His initial laboratory investigations revealed hyperglycemia, high anion gap metabolic acidosis, ketonuria, and glycosuria. His relatives revealed intentional ingestion of OPC. He was treated for both OPC poisoning and hyperglycemic ketoacidosis. Adequate acute care was instigated though prognosis could not be gauged due to the early discharge of the patient against medical advice. This case highlights that OPC poisoning can be a possible etiological factor for hyperglycemic ketoacidosis. It can mimic diabetic ketoacidosis leading to delayed diagnosis. Thus, early identification and immediate management are crucial because of the effect of hyperglycemic ketoacidosis on the outcome of a patient with OPC poisoning.

Overlapping risk factors for diabetic ketoacidosis in patients with type 1 diabetes on ipragliflozin: case analysis of spontaneous reports in Japan from a pharmacovigilance safety database

BACKGROUND

In patients with type 1 diabetes mellitus (T1D), sodium-glucose cotransporter 2 (SGLT2) inhibitors are associated with an increased risk of diabetic ketoacidosis (DKA). Ipragliflozin is an SGLT2 inhibitor approved in Japan in combination with insulin for patients with T1D.

RESEARCH DESIGN AND METHODS

Spontaneous safety reports of ipragliflozin adverse drug reactions (ADRs) in patients with T1D were collected during early post-marketing phase vigilance (EPPV; 21 December 2018-20 June 2019). For patients with T1D prescribed ipragliflozin who experienced DKA, we examined DKA event data registered in the manufacturer's safety database (21 December 2018-31 December 2021), including patient background characteristics.

RESULTS

During EPPV, there were 189 total events (45 serious) of ADRs, including 32 serious events of ketoacidosis. From 2018 to 2021, the major DKA risk factors were sick days, stopping or inappropriately decreasing insulin, insulin pump trouble, and low carbohydrate diet, with substantial overlap among these factors.

CONCLUSIONS

In Japanese patients with T1D using ipragliflozin, DKA events were linked to several overlapping factors, including sick days and reduced dose/interruption of insulin, whether intentional or unexpected. These results highlight the need for improved patient education regarding ipragliflozin use and appropriate self-management of ketosis from an early stage.

The Computational Acid-Base Chemistry of Hepatic Ketoacidosis

Opposing evidence exists for the source of the hydrogen ions (H⁺) during ketoacidosis. Organic and computational chemistry using dissociation constants and alpha equations for all pertinent ionizable metabolites were used to (1) document the atomic changes in the chemical reactions of ketogenesis and ketolysis and (2) identify the sources and quantify added fractional (~) H⁺ exchange (~H⁺e). All computations were performed for pH conditions spanning from 6.0 to 7.6. Summation of the ~H⁺e for given pH conditions for all substrates and products of each reaction of ketogenesis and ketolysis resulted in net reaction and pathway ~H⁺e coefficients, where negative revealed ~H⁺ release and positive revealed ~H⁺ uptake. Results revealed that for the liver (pH = 7.0), the net ~H⁺e for the reactions of ketogenesis ending in each of acetoacetate (AcAc), β-hydroxybutyrate (β-HB), and acetone were -0.9990, 0.0026, and 0.0000, respectively. During ketogenesis, ~H⁺ release was only evident for HMG CoA production, which is caused by hydrolysis and not ~H⁺ dissociation. Nevertheless, there is a net ~H⁺ release during ketogenesis, though this diminishes with greater proportionality of acetone production. For reactions of ketolysis in muscle (pH = 7.1) and brain (pH = 7.2), net ~H⁺ coefficients for β-HB and AcAc oxidation were -0.9649 and 0.0363 (muscle), and -0.9719 and 0.0291 (brain), respectively. The larger ~H⁺ release values for β-HB oxidation result from covalent ~H⁺ release during the oxidation-reduction. For combined ketogenesis and ketolysis, which would be the metabolic condition in vivo, the net ~H⁺ coefficient depends once again on the proportionality of the final ketone body product. For ketone body production in the liver, transference to blood, and oxidation in the brain and muscle for a ratio of 0.6:0.2:0.2 for β-HB:AcAc:acetone, the net ~H⁺e coefficients for liver ketogenesis, blood transfer, brain ketolysis, and net total (ketosis) equate to -0.1983, -0.0003, -0.2872, and -0.4858, respectively. The traditional theory of ketone bodies being metabolic acids causing systemic acidosis is incorrect. Summation of ketogenesis and ketolysis yield H⁺ coefficients that differ depending on the proportionality of ketone body production, though, in general, there is a small net H⁺ release during ketosis. Products formed during ketogenesis (HMG-CoA, acetoacetate, β-hydroxybutyrate) are created as negatively charged bases, not acids, and the final ketone body, acetone, does not have pH-dependent ionizable groups. Proton release or uptake during ketogenesis and ketolysis are predominantly caused by covalent modification, not acid dissociation/association. Ketosis (ketogenesis and ketolysis) results in a net fractional H⁺ release. The extent of this release is dependent on the final proportionality between acetoacetate, β-hydroxybutyrate, and acetone.

Induction of remission in diabetes by lowering blood glucose

As diabetes continues to grow as major health problem, there has been great progress in understanding the important role of pancreatic beta-cells in its pathogenesis. Diabetes develops when the normal interplay between insulin secretion and the insulin sensitivity of target tissues is disrupted. With type 2 diabetes (T2D), glucose levels start to rise when beta-cells are unable to meet the demands of insulin resistance. For type 1 diabetes (T1D) glucose levels rise as beta-cells are killed off by autoimmunity. In both cases the increased glucose levels have a toxic effect on beta-cells. This process, called glucose toxicity, has a major inhibitory effect on insulin secretion. This beta-cell dysfunction can be reversed by therapies that reduce glucose levels. Thus, it is becoming increasingly apparent that an opportunity exists to produce a complete or partial remission for T2D, both of which will provide health benefit.

Potential Ketoacidosis Linked to Imeglimin and Metformin Co-administration in a Patient With Type 2 Diabetes

A 74-year-old woman with type 2 diabetes mellitus developed ketoacidosis within six days of adding metformin to imeglimin treatment. The patient was insulin-sensitive and showed preserved insulin secretion; therefore, insulin insufficiency alone was unlikely to contribute to the development of ketoacidosis. Both imeglimin and metformin partially inhibit complex I in the mitochondrial respiratory chain. Inhibition of mitochondrial respiration can lead to tricarboxylic acid (TCA) cycle suppression. Thus, the entry of acetyl-coenzyme A into TCA cycle is restricted, and it is eventually used in ketogenesis. Therefore, the combination of imeglimin and metformin might have precipitated the development of ketoacidosis.

The Evaluation and Management of Pediatric Diabetic Ketoacidosis: A Comprehensive Review

Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.

Starvation Ketoacidosis in a Young Healthy Female After Prolonged Religious Fasting

Ketone bodies are important energy sources for the body and are produced by the liver when the body is in a deficiency state of glucose, which is used in the peripheral tissues to provide energy. There are several ketone bodies that are produced by the liver, of which two are important: acetoacetate and beta-hydroxybutyrate. Even though ketone bodies are always present in the body, they are minimal when a person is not fasting. Ketone bodies are produced by the oxidation of fatty acids to fulfill the metabolic needs of tissues, especially the brain. The biochemical reactions of forming ketone bodies are triggered by a lack of insulin and an elevated glucagon level in the blood. Both cause unopposed lipolysis and free fatty acid oxidation resulting in the production of ketone bodies and eventually high anion gap metabolic acidosis. We present a case of young healthy female who presented with euglycemic ketoacidosis after involving prolonged fasting for her religious ceremony. She also physically exerted quite more during her fasting. With a detailed history and excluding other possibilities, we made the diagnosis of starvation ketoacidosis. She improved well with the treatment and established her pre-morbid condition in our review.

The Relationship between Type 1 Diabetes Mellitus, TNF-α, and IL-10 Gene Expression

Type 1 diabetes mellitus (T1DM) is one of the major chronic diseases in children worldwide. This study aimed to investigate interleukin-10 (IL-10) gene expression and tumor necrosis factor-alpha (TNF-α) in T1DM. A total of 107 patients were included, 15 were T1DM in ketoacidosis, 30 patients had T1DM and HbA1c ≥ 8%; 32 patients had T1DM and presented HbA1c < 8%; and 30 were controls. The expression of peripheral blood mononuclear cells was performed using the reverse transcriptase-polymerase chain reaction in real time. The cytokines gene expression was higher in patients with T1DM. The IL-10 gene expression increased substantially in patients with ketoacidosis, and there was a positive correlation with HbA1c. A negative correlation was found for IL-10 expression and the age of patients with diabetes, and the time of diagnosis of the disease. There was a positive correlation between TNF-α expression with age. The expression of IL-10 and TNF-α genes showed a significant increase in DM1 patients. Once current T1DM treatment is based on exogenous insulin, there is a need for other therapies, and inflammatory biomarkers could bring new possibilities to the therapeutic approach of the patients.

Peri-colonoscopy Implications of Sodium-Glucose Cotransporter-2 Inhibitor Therapy: A Mini-review of Available Evidence

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a class of oral glucose-lowering agents commonly used for the treatment of type 2 diabetes. With increased use, there has been an increase in the incidence of the rare but life-threatening complication of euglycemic diabetic ketoacidosis. A common but underappreciated precipitant is colonoscopy. In this work, we outline the pathophysiology of the interaction between colonoscopy and SGLT2i use, the evidence regarding SGLT2i use in the periprocedural setting and Australian Diabetes Society guidelines.

Acid-Base Disorders in the Critically Ill Patient

Acid-base disorders are common in the intensive care unit. By utilizing a systematic approach to their diagnosis, it is easy to identify both simple and mixed disturbances. These disorders are divided into four major categories: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Metabolic acidosis is subdivided into anion gap and non-gap acidosis. Distinguishing between these is helpful in establishing the cause of the acidosis. Anion gap acidosis, caused by the accumulation of organic anions from sepsis, diabetes, alcohol use, and numerous drugs and toxins, is usually present on admission to the intensive care unit. Lactic acidosis from decreased delivery or utilization of oxygen is associated with increased mortality. This is likely secondary to the disease process, as opposed to the degree of acidemia. Treatment of an anion gap acidosis is aimed at the underlying disease or removal of the toxin. The use of therapy to normalize the pH is controversial. Non-gap acidoses result from disorders of renal tubular H + transport, decreased renal ammonia secretion, gastrointestinal and kidney losses of bicarbonate, dilution of serum bicarbonate from excessive intravenous fluid administration, or addition of hydrochloric acid. Metabolic alkalosis is the most common acid-base disorder found in patients who are critically ill, and most often occurs after admission to the intensive care unit. Its etiology is most often secondary to the aggressive therapeutic interventions used to treat shock, acidemia, volume overload, severe coagulopathy, respiratory failure, and AKI. Treatment consists of volume resuscitation and repletion of potassium deficits. Aggressive lowering of the pH is usually not necessary. Respiratory disorders are caused by either decreased or increased minute ventilation. The use of permissive hypercapnia to prevent barotrauma has become the standard of care. The use of bicarbonate to correct the acidemia is not recommended. In patients at the extreme, the use of extracorporeal therapies to remove CO 2 can be considered.

Type 1 diabetes in low and middle-income countries - Tanzania a streak of hope

INTRODUCTION

In several of the Low and Middle Income countries , many patients with Type 1 diabetes (T1D) are most probably not diagnosed at all which may contribute to their low incidence. As an example of a country with low income and poor resources, we have chosen to study T1D in children/young people in Tanzania.

METHODS

Analyses of casebooks and statistics at several Tanzanian hospitals treating young patients with insulin dependent diabetes, usually Type 1 diabetes, and collection of information from different organisations such a Tanzanian Diabetes Association, Life for a Child, Changing Diabetes in Children and World Diabetes Foundation.

RESULTS

The incidence in several areas is low. However, a lot of data are often missing at studied clinics and therefore the incidence might be higher, and with increased awareness in recent years the number of patients has increased many-folds. Most patients present with typical symptoms and signs of T1D, and a high proportion with plausible ketoacidosis , although this proportion has decreased from about 90% to about 40% in recent decades. Many patients have poor blood glucose control, and complications often develop already after short diabetes duration. In recent years resources have increased, awareness has increased and diabetes clinics started where staff has got training.

CONCLUSIONS

There are problems with diabetes care in Tanzania but several facts give hope for the future.

Delayed onset of impaired consciousness complicated with ketoacidosis after disulfiram overdose

Background

We report a case of disulfiram overdose that caused a delayed onset of impaired consciousness and ketoacidosis.

Case presentation

A 61-year-old man was transferred to our hospital following a suicide attempt. The patient lost consciousness after an overdose of disulfiram and brotizolam. He was diagnosed with acute drug intoxication and was intubated. On day 2, he showed an improved consciousness response and was successfully extubated. On day 5, the state of consciousness worsened again, and ketoacidosis progressed. The patient required hemodialysis and suffered from impaired consciousness for the following 2 weeks. Eventually, he recovered gradually and was discharged to the rehabilitation ward.

Conclusions

The delayed appearance of symptoms after the disulfiram overdose was thought to be related to the slow metabolism of disulfiram in the body. Our case suggests the necessity of careful follow-up for delayed impaired consciousness.

Ketosis-prone Diabetes and Hypogonadism: A New Clinical Association to be Aware of ?

BACKGROUND

Ketosis-prone diabetes (KPD) is an emerging entity, sharing features of both type 1 diabetes mellitus and type 2 diabetes mellitus. Patients with KPD usually present with diabetic ketoacidosis without the classic phenotype of autoimmune type 1 diabetes. In most cases, they are Afro-American adults, who require insulin therapy for the management of acute decompensation, then usually encountering insulin-free remission for prolonged periods of time with diet or with non-insulin agents. Meanwhile, hypogonadism is a known condition that could be associated with higher risk of developing both type 1 and type 2 diabetes and could be a risk factor for decompensated diabetes. The association of KPD and hypogonadism is reported for the first time in literature.

CASE PRESENTATION

Here we report two peculiar cases of young African patients, affected by KPD and hypergonadotropic hypogonadism, respectively Klinefelter's syndrome and primary ovarian failure. Both patients were treated promptly for the ketoacidosis with intravenous fluids combined with continuous insulin infusion, and then switched to subcutaneous regimen. After the correct clinical evaluation, oral antidiabetic drugs were added.

CONCLUSION

KPD remains an under-recognized and under-diagnosed type of diabetes. As hypogonadism is strongly linked to dysmetabolic disorders, the evaluation of sex hormones should be performed at the onset of diabetes. Further studies should investigate the hypothalamic-pituitary-gonadal axis and its role in the development of KDP and its manifestations and complications.

The association between plasma carnitines and duration of diabetic ketoacidosis treatment in children with type 1 diabetes

OBJECTIVES

The aim of this study is to determine the plasma free carnitine and acyl-carnitine levels at the time of diabetic ketoacidosis (DKA) diagnosis, and at the end of DKA treatment and to investigate their association with the duration of DKA treatment in children with DKA.

METHODS

A total of 40 children with DKA who were treated consecutively in a tertiary health center for DKA were included in the study. The median age of the children was 11.3 years (1.1-17.5) and 25 of them (62.5%) were girls. In addition to routine blood tests, plasma free carnitine and acyl-carnitine levels were measured just before the start of intravenous insulin therapy and at the time of discontinuation of intravenous insulin therapy when DKA therapy was completed.

RESULTS

There was no difference in plasma free carnitine and acyl-carnitine levels before and after DKA treatment (p=0.776 and p=0.743 respectively). However, while the frequency of low plasma free carnitine was 30% at the beginning of the treatment, it was observed that this frequency was 20% at the end of the DKA treatment. There was no correlation between duration of DKA treatment and plasma free carnitine or acyl-carnitine levels at admission (p=0.497, r=-0.111 and p=0.474, r=0.116 respectively).

CONCLUSIONS

There is no a relationship between duration of DKA treatment and plasma free carnitine or acyl-carnitine level at admission in children with DKA.

Euglycemic diabetic ketoacidosis and COVID-19 management in a term pregnant patient; a case report

In this case report, we report a Covid-19 infected female patient with gestational diabetes mellitus with primary manifestation of ketoacidosis at term pregnancy and discuss the management challenges with euglycemia and a high ketone burden.

New insights into cellular links between sodium-glucose cotransporter-2 inhibitors and ketogenesis

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a newly developed class of highly effective antidiabetic therapies that normalize hyperglycemia via urinary glucose excretion. However, they may be accompanied by certain side effects that negatively impact their therapeutic benefits. SGLT2is induce a metabolic shift from glucose to fatty acids and thus increase lipolysis which, in turn, induces ketogenesis. The complete pathways linking SGLT2is to ketoacidosis have not yet been fully elucidated, though much is now known. Therefore, in this mechanistic study, we present the current knowledge and shed light upon the possible cellular pathways involved. A deeper understanding of the possible links between SGLT2is and ketogenesis could help to prevent adverse side effects in diabetic patients treated with these drugs.

Accidental Acetone Ingestion in Liver Transplant Patient With Alcohol Relapse: A Case Report

Acetone is one of the three main types of ketone bodies that can be found in ketoacidosis, along with acetoacetate, and beta-hydroxybutyrate. Any of these three ketone bodies can be found in the blood after the natural breakdown of fatty acids in diabetes, starvation, or alcoholic ketoacidosis. However, a patient can also develop acetone poisoning from ingestion of common household products such as nail polish removers, paint removers, isopropyl alcohol, or other detergents and cleaners. Ingestion is usually accidental in adults and children and can lead to severe damage to the liver, heart, nervous system, and kidneys. In rare cases, large amounts of ingestion can lead to life-threatening conditions or death. Our case reports a man with a history of alcoholic cirrhosis status post liver transplantation, who unintentionally ingested acetone, mistaking the contents of small bottles for vodka. The patient presented with several syncopal episodes, anion gap metabolic acidosis, transaminitis with hyperbilirubinemia, and pancreatitis.

Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes

CONTEXT

Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency with risk of maternofetal death.

OBJECTIVE

This work aimed to evaluate DKA events in pregnant women admitted to our inpatient obstetric service, and to examine associated clinical risk factors, presentation, and pregnancy outcomes.

METHODS

A retrospective cohort study was conducted at the Mayo Clinic, Rochester, Minnesota, USA, and included women aged 17 to 45 years who were treated for DKA during pregnancy between January 1, 2004 and December 31, 2021. Main outcome measures included maternal and fetal death along with a broad spectrum of maternal and fetal pregnancy outcomes.

RESULTS

A total of 71 DKA events were identified in 58 pregnancies among 51 women, 48 (82.8%) of whom had type 1 diabetes. There were no maternal deaths, but fetal demise occurred in 10 (17.2%) pregnancies (6 miscarriages and 4 stillbirths). Maternal social stressors were frequently present (n = 30, 51.0%), and glycemic control was suboptimal (median first trimester glycated hemoglobin A1c = 9.0%). Preeclampsia was diagnosed in 17 (29.3%) pregnancies. Infants born to women with DKA were large for gestational age (n = 16, 33.3%), suffered from neonatal hypoglycemia (n = 29, 60.4%) and required intensive care unit admission (n = 25, 52.1%).

CONCLUSION

DKA is associated with a high rate of maternofetal morbidity and fetal loss. Prenatal education strategies for women with diabetes mellitus should include a strong focus on DKA prevention, and clinicians and patients should have a high index of suspicion for DKA in all pregnant women who present with symptoms that could be attributed to this condition.

Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding

In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m². Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.

An Audit of Factors Impacting the Time to Resolution of the Metabolic Parameters in Diabetic Ketoacidosis Patients

INTRODUCTION

Diabetic ketoacidosis (DKA) is a major complication affecting patients with diabetes. It is often the first presentation of type I diabetes and can also occur due to a lack of compliance with insulin therapy or infection, among other causes. Hospitalizations for DKA have increased globally among patients with type I and type II diabetes, which poses a strain on health systems.

AIM

To determine the factors impacting the time to resolution of metabolic parameters in DKA patients.

METHODS

This retrospective study was performed by reviewing the clinical records of hospitalized DKA patients at King Fahad Specialist Hospital, a tertiary-level healthcare center in Buraidah, Al Qassim region, Saudi Arabia. The study included all DKA admissions that met the inclusion criteria between September 2019 and April 2022.

RESULTS

A total of 129 patients with a diagnosis of DKA from January 2019 to April 2022 were identified. Of these, 67 patients met the inclusion criteria. More females experienced DKA (56.7%), and the study population had an improvement rate of 97%. The mean length of stay (LOS) for patients with DKA was 73.19 hours, and the median time for DKA resolution was 15 hours (mean time 21.38 hours). The omission of insulin was the leading precipitating factor for DKA (43%) followed by infection (12%). A high serum bicarbonate (HCO₃₎ level was identified as an independent predictor for a longer time to resolution. Patients with DKA who have high glucose levels on admission, higher body mass index (BMI), older age, and higher weight stayed in the hospital for extended periods. Conversely, patients with a higher serum potential of Hydrogen (pH) had a shorter LOS. Age was the only clinically independent predictor for a minimum LOS for DKA. Patients with comorbidities had a longer hospital LOS than patients without comorbidities; no such relationship has been reported in other studies. Patients in our study population had a longer time of resolution than observed in other studies, although no clear cause was identified.

CONCLUSION

This study contributes to our understanding of DKA in hospitalized patients in Saudi Arabia. This is the first study to link patients with DKA who have comorbidities to a longer hospital stay in the kingdom of Saudi Arabia. This study also identified multiple clinical and biochemical parameters related to the variability in LOS and time to resolution of DKA in hospitalized patients.

Ketoacidosis in a Patient with Type 2 Diabetes Requiring Alpelisib: Learnings and Observations Regarding Alpelisib Initiation and Rechallenge

Background

Diabetic ketoacidosis (DKA) is a rare complication of alpelisib, but cases of DKA are reported. Alpelisib's safety in patients with long-standing, suboptimally controlled diabetes is unclear since clinical trials of alpelisib did not include them.

Case

A case is presented on a patient with metastatic breast cancer and type 2 diabetes admitted for DKA eleven days after starting alpelisib. Since DKA is implicated in antihyperglycemics that inhibit sodium-glucose cotransporter-2 (SGLT2) inhibitors, her empagliflozin was discontinued. Alpelisib was also held since it was recently initiated. After the DKA resolved, she was discharged and restarted alpelisib. Within 4 hours of taking the first dose, the patient developed a second episode of DKA, and alpelisib treatment was stopped permanently.

Conclusion

Patients with long-standing type 2 diabetes are at high risk of alpelisib-induced Grade 3 and 4 hyperglycemia, including DKA. It is essential to communicate with non-oncology stakeholders about the risk of DKA with alpelisib as it can be overlooked for more common causes. Restarting alpelisib can result in severe hyperglycemia or DKA within 24 hours of the first dose. In this population, the risks associated with rechallenging alpelisib must be heavily weighed against its benefits. Before restarting alpelisib, a thorough evaluation of the appropriateness of the patient's antihyperglycemics and diet must occur to anticipate and mitigate a second event. Antihyperglycemics independent of the PI3K/AKT/mTOR pathway may be preferred agents. A plan should be in place to quickly respond to rising glycemia and early referral to a diabetologist or endocrinologist is recommended. Continuous glucose monitoring and hospital admission are recommended during rechallenge. A better understanding of alpelisib-induced hyperglycemia, especially in patients with diabetes, is required to navigate alpelisib treatment safely. Emphasis should be placed on patient education of symptoms and monitoring parameters.

Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia

INTRODUCTION

Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus that carries a significant risk of mortality with delayed treatment in low-resource countries. This study aimed to determine the outcome of paediatric DKA patients' managed with a modified DKA treatment protocol using intermittent bolus subcutaneous insulin administration.

METHODS

A cross-sectional study design with retrospective data collection was conducted among children younger than 14 years of age admitted from January 2013 to February 2017. A modified protocol was prepared based on a reference from the international society for paediatric and adolescent diabetes and other international guidelines. Data were analysed using Statistical package for social science (SPSS) version 22.0. Descriptive statistics were performed. Binary logistic regression was used to identify associations, and significant variables were further considered for multivariate logistic regression to determine the outcome of DKA patients.

RESULT

Among the 190 patients, 55.5% (n = 105) were newly diagnosed. The overall average time required for resolution of DKA was 48 ± 27.8 h. Mental status on presentation (p = .001), shock on presentation (p < .01) and severity of DKA (p < .001) were found to have a significant association with the mean time for clearance of DKA. Hypoglycaemia was the most common treatment-related complication, which occurred in 23.7% of patients (n = 45) followed by hypokalaemia in 4.3% of patients (n = 8), and no patient developed cerebral oedema and death.

CONCLUSION

The time required for clearance of DKA was prolonged, and hypoglyceamia was a common complication for children younger than 5 years of age. The modified protocol of DKA is reasonable management for low-resource settings with further modification.

A case study of acute oropharyngeal palsy concomitant with diabetic ketoacidosis

Acute oropharyngeal palsy is a rare variant of Guillain-Barré syndrome. In our study we present the case of a 63-year-old man with general symptoms who was diagnosed with diabetic ketoacidosis and prescribed insulin therapy. Two weeks later, the patient complained of paraesthesia of the perioral region and the tip of the tongue, dysphagia, and dysarthria. These symptoms were initially thought to be complications of the patient's type-1 diabetes. Due to rapidly developing paraparesis, the patient became bedridden. Clinical symptoms, cerebrospinal fluid analysis and a nerve conduction study resulted in a diagnosis of acute oropharyngeal palsy, a variant of Guillain-Barré syndrome. After five consecutive days of intravenous immunoglobulin treatment, neurological symptoms improved and the need for insulin ceased. One year later, the patient's only remaining neurological symptom was loss of tendon reflexes in the lower extremities. Furthermore, the patient's blood glucose level was normal without the use of medications or a special diet. Here, we report that oropharyngeal palsy can co-occur with diabetic ketoacidosis, and that immuntherapy is effective in treating both oropharyngeal palsy and type-1 diabetes. To our knowledge, this is the first description of a patient presenting with acut oropharyngeal palsy concomitant with diabetic ketoacidosis.

Continuous Ketone Monitoring Consensus Report 2021

This article is the work product of the Continuous Ketone Monitoring Consensus Panel, which was organized by Diabetes Technology Society and met virtually on April 20, 2021. The panel consisted of 20 US-based experts in the use of diabetes technology, representing adult endocrinology, pediatric endocrinology, advanced practice nursing, diabetes care and education, clinical chemistry, and bioengineering. The panelists were from universities, hospitals, freestanding research institutes, government, and private practice. Panelists reviewed the medical literature pertaining to ten topics: (1) physiology of ketone production, (2) measurement of ketones, (3) performance of the first continuous ketone monitor (CKM) reported to be used in human trials, (4) demographics and epidemiology of diabetic ketoacidosis (DKA), (5) atypical hyperketonemia, (6) prevention of DKA, (7) non-DKA states of fasting ketonemia and ketonuria, (8) potential integration of CKMs with pumps and automated insulin delivery systems to prevent DKA, (9) clinical trials of CKMs, and (10) the future of CKMs. The panelists summarized the medical literature for each of the ten topics in this report. They also developed 30 conclusions (amounting to three conclusions for each topic) about CKMs and voted unanimously to adopt the 30 conclusions. This report is intended to support the development of safe and effective continuous ketone monitoring and to apply this technology in ways that will benefit people with diabetes.

A study of diabetic ketoacidosis in the pregnant population in the United Kingdom: Investigating the incidence, aetiology, management and outcomes

AIM

To estimate the incidence of diabetic ketoacidosis (DKA) among pregnant women, describe its clinical features, management and outcomes and identify the risk factors for the condition.

METHODS

A national population-based case-control study was conducted in the UK using the UK Obstetric Surveillance System between April 2019 and September 2020 including all pregnant women with DKA irrespective of the level of blood glucose. The incidence rate of DKA in pregnancy was estimated. A case-control analysis limited to women with type 1 diabetes was performed comparing characteristics of women with DKA (cases) to those of women whose pregnancies were not complicated by DKA (controls).

RESULTS

In all, 82 women were identified with DKA in pregnancy; 6.3 per 100,000 maternities (95% CI: 5.0-7.9). No maternal deaths occurred, but perinatal mortality was 12/73 (16%) with 11 stillbirths and one neonatal death. DKA episodes mostly occurred in women with type 1 diabetes (85%) and in the 3^rd trimester of pregnancy (71%). Episodes were mainly precipitated by infection (21%), vomiting (21%), steroid therapy (13%) and medication errors (10%). Fifteen percent of women had more than one episode of DKA during their pregnancy. Risk factors associated with DKA among women with type 1 diabetes identified through the case-control analysis were the woman and/or partner not being in a paid employment and having at least one microvascular complication of diabetes before pregnancy.

CONCLUSION

DKA in pregnancy was associated with high perinatal mortality and was linked with factors related to socio-economic deprivation, mental health problems and long-term difficulties with glycaemic control.

The cross-talk between mucormycosis, steroids and diabetes mellitus amidst the global contagion of COVID-19

Mucormycosis is an opportunistic fungal disease that targets individuals having an impaired immune system due to a wide array of risk factors including HIV-AIDS, immunosuppressive therapy, diabetes mellitus, etc. The current explosive outbreak of coronavirus disease 2019 (COVID-19) has become the latest threat to such patients who are already susceptible to secondary infections. Physiological outcomes of COVID-19 end up in a cascade of grave alterations to the immunological profile and irreparable harm to their respiratory passage, heart and kidneys. Corticosteroidal treatment facilitates faster recovery and alleviates the adverse pathological effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). But clinical reports lend this approach a darker perspective especially if these patients have pre-existing diabetes mellitus. The mucormycotic fungal genera belonging to the order Mucorales not only survive but thrive under the comorbidity of COVID-19 and diabetes, often staying undetected until they have inflicted irreversible damage. Steroidal usage has been noted to be a common thread in the sudden spurt in secondary fungal infections among COVID-19 cases. Once considered a rare occurrence, mucormycosis has now acquired a notoriously lethal status in mainstream medical hierarchy. We set out to investigate whether corticosteroidal therapy against COVID-19 emboldens the development of mucormycosis. We also assess the conditions brought forth by steroidal usage and uncontrolled progression of diabetes in COVID-19 cases and their effect on the susceptibility towards mucormycosis.

Biological Mechanisms behind Wischnewsky Spots Finding on Gastric Mucosa: Autopsy Cases and Literature Review

Hypothermia is an emergency caused by the lowering of the central body temperature with a slowdown of basic vital functions. Reduced mobility, old age, psychiatric or metabolic disorders are relevant risk factors. Diagnosis of death from hypothermia is a challenge, as there are no pathognomonic signs, and supportive findings can be inconstant. Wischnewsky Spots (WS) are blackish lesions of gastric mucosa, typically associated with hypothermic death. The pathophysiology of these lesions is still uncertain. The aim of this paper is to investigate the pathological mechanisms determining the appearance of WS by analyzing the current scientific knowledge in this area. We performed a narrative review of the literature published in the last 20 years, comparing the results with three cases of hypothermia reported from our experience. The review proved that WS show a multifactorial etiology, i.e., not only body temperature decrease, but also various extrinsic and intrinsic factors, such as physical and psychological stress, agony, causa mortis and metabolic comorbidities. The review summarizes the current knowledge in the field of incidence, pathology and morphology of WS by proposing some scientific and technical points for clinical and forensic analysis of this phenomenon.

A Case Series of Ketoacidosis After Coronavirus Disease 2019 Vaccination in Patients With Type 1 Diabetes

Introduction

We report a case series of severe ketoacidosis after COVID-19 vaccination in a type 1 diabetes patients treated with insulin and an SGLT-2 inhibitor.

Case Report

We present two cases of type 1 diabetes mellitus. One patient was treated with insulin therapy and an SGLT-2 inhibitor, and the other patient was treated with insulin therapy alone. Both patients became ill after coronavirus disease-2019 vaccination, making it difficult to continue their diet or insulin injections. On admission, they developed severe diabetic ketoacidosis. This is the first report of ketoacidosis after coronavirus disease-2019 vaccination.

Conclusion

The vaccine should be carefully administered to type 1 diabetes patients receiving intensive insulin therapy and a sodium-glucose transporter due to the high risk ketoacidosis. It is important to instruct patients to drink sufficient fluids and to continue insulin injections when they become sick.

Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis Induced by Soft Drink Polydipsia in a Patient with Occult Central Diabetes Insipidus

A 21-year-old Japanese man without known diabetes mellitus had abdominal pain. The diagnosis was ketoacidosis and hypertriglyceridemia-induced acute pancreatitis. He had polydipsia and polyuria and had habitually drunk several soft drinks every day for two years. After hospitalization, despite adequate liquid intake, dehydration remained with hypotonic polyuria. Further examinations revealed the coexistence of central diabetes insipidus (CDI), possibly caused by lymphocytic infundibulo-neurohypophysitis, based on anti-rabphilin-3A antibody positivity. Although CDI had been undiagnosed for two years, over-consumption of sugar-rich soft drinks to ease thirst caused ketoacidosis, hypertriglyceridemia, and acute pancreatitis. There are no previous reports of this three-part combination of symptoms caused by CDI.

Association of type 1 diabetes and educational achievement in 16-20-year-olds: A Danish nationwide register study

AIMS

The objective of the study was to compare grade point averages (GPAs) on compulsory school exit exams (exam GPA) and educational attainment at age 16 and 20 for individuals with and without type 1 diabetes.

METHODS

This study was a population-based retrospective cohort study, which included the 1991 to 1998 birth cohorts in Denmark. Follow-up was conducted at age 16 and 20 (follow-up period; 1 January, 2007 to 31 December, 2018). There were 2083 individuals with and 555,929 individuals without type 1 diabetes. Linear regression and generalized linear models compared outcomes with and without adjustments for socio-economic characteristics.

RESULTS

A total of 558,012 individuals (51% males) were followed to the age of 20. Having type 1 diabetes was associated with a lower exam GPA when adjusting for socio-economic status (difference: -0.05 (95% CI, -0.09 to -0.01), a higher relative risk of not completing compulsory school by age 16 (1.37, 95% CI, 1.22 to 1.53)), and a higher relative risk of not completing or being enrolled in upper secondary education by age 20 (1.05, 95% CI, 1.00 to 1.10). Haemoglobin A1c (HbA1c) <58 mmol/mol (7.5%), >7 BGM/day and insulin pump use were associated with better educational achievement.

CONCLUSION

Type 1 diabetes was associated with a marginally lower exam GPA and a higher risk of not completing compulsory school by age 16 and lower educational attainment by age 20. The findings were modified by HbA1c, BGM and insulin pump use.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Ketoacidosis in new-onset type 1 diabetes: did the severity increase during the COVID-19 pandemic?

OBJECTIVES

Since the beginning of the COVID-19 pandemic, there has been a consistent decrease in the number of admissions to the emergency department, leading to a delay in the diagnosis of several pathologies. The time from onset of symptoms to the diagnosis of Type 1 diabetes is highly variable. This treatment delay can lead to the appearance of ketoacidosis.

METHODS

Retrospective study of inaugural Type 1 diabetes cases, from March 2016 to March 2021. The pandemic group was considered between March 2020 to March 2021, and the remaining period was considered as pre-pandemic. Clinical variables were analysed: duration of symptoms, weight loss and value of ketonemia and glycated haemoglobin on admission. The mean differences were considered statistically significant at p<0.05.

RESULTS

103 inaugural episodes of Type 1 diabetes were registered. The pandemic group had a lower mean age when compared to pre-pandemic group, and 51.7% of the episodes had ketoacidosis with a higher relative risk of ketoacidosis and severe ketoacidosis, when compared the pandemic with pre-pandemic group, there was a longer symptom evolution time (34 vs. 20 days), greater weight loss occurred (9.5% vs. 6.3%), the pH and HCO₃ ^- values were lower (7.30 vs. 7.36 and 16.43 vs. 20.71 mmol/L respectively) and ketonemia was higher (5.9 vs. 2.3 mmol/L).

CONCLUSIONS

The COVID-19 pandemic caused a delay in the diagnosis of Type 1 diabetes, greater length of disease, greater weight loss, higher ketonemia and lower pH and HCO₃ ^-. There was greater ketoacidosis relative risk in pandemic group when compared to pre-pandemic group.

Methamphetamine use and the risk of diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a life-threatening condition arising in individuals with insulin-dependent diabetes mellitus, associated with hyperglycaemia and hyperketonaemia. While drugs such as methadone, cocaine and certain prescription medications may precipitate DKA, the potential effect of methamphetamine is unclear. Analysis of autopsy and toxicology case files at Forensic Science SA, Adelaide, South Australia, was therefore undertaken from 1 January to 31 December 2019 of all cases where methamphetamine was detected in post-mortem blood samples. There were 94 cases with 11 diabetics (n = 6 type 1 and n = 5 type 2). Four of the six decedents with type 1 diabetes had lethal DKA (66.7%; age range 30-54 years; average age 44.6 ± 10.5 years; M:F ratio 1:1). This incidence of DKA was higher than that of the general insulin-dependent diabetic population (6%) and also significantly higher than in medico-legal cases (13%; p < 0.05). The clinical and autopsy assessment of insulin-dependent diabetics presenting with DKA should therefore include specific screening for methamphetamine. The increase in both insulin-dependent diabetes and methamphetamine abuse in the community may lead to increases in such cases in medico-legal and health contexts.

Alarming Increase of Ketoacidosis Prevalence at Type 1 Diabetes-Onset in Austria-Results From a Nationwide Registry

OBJECTIVE

We analyzed the annual prevalence of onset-DKA (diabetic ketoacidosis) from 2012 to 2020 with a sub-analysis for lockdown-periods during the COVID-19 pandemic in 2020.

DESIGN

All newly diagnosed children with type 1 diabetes (T1D) aged <15 years are prospectively registered in the population-based Austrian Diabetes Incidence Study in Austria.

MAIN OUTCOME MEASURES

The annual DKA prevalence was analyzed using Joinpoint regression. Definition of DKA: pH <7.3, mild DKA: pH 7.3 to ≤ 7.1, severe DKA: pH <7.1. DKA prevalence during the lockdown periods in 2020 and the corresponding periods in 2015-2019 were examined using Fisher's exact test.

RESULTS

In the years 2012-2020 the mean prevalence for onset-DKA in Austria was 43.6% [95%CI (confidence interval): 41.6, 45.7] and thus above the mean prevalence of previous decades (1989-2011) of 37,1 % (95%CI: 35.6, 38.6). A particularly high prevalence was found among children <2 years of age (72.0% DKA, 32.8% severe DKA). No significant gender difference was found. Prevalence of severe DKA at T1D-onset increased significantly since 2015 (p = 0.023). During the lockdown in 2020, 59.3% of children were diagnosed with DKA at T1D-onset, compared to 42.1% during the previous 5 years (p = 0.022). Moreover, 20% of children had severe DKA at T1D diagnosis, compared to 14% during the comparison period.

CONCLUSIONS

The previously already high prevalence of DKA at T1D-onset has further increased over time. The COVID-19 pandemic has exacerbated the problem of a late or delayed diagnosis of diabetes in children resulting in onset-DKA. The alarmingly increased prevalence of DKA in Austrian children with T1D calls for urgent action.

Storm of a rare opportunistic life threatening mucormycosis among post COVID-19 patients: A tale of two pathogens

Mucormycosis is a rare but life-threatening opportunistic fungal infection caused by a group of molds that belong to Zygomycetes of the order Mucorales. These fungi are found in the environment such as soil, decaying vegetation, and organic matters. Sporangiospores present in the environment enter the human body through inhalation or direct skin inoculation by trauma or ingestion and result in pulmonary, cutaneous, and gastrointestinal mucormycosis, respectively, in immunocompromised hosts. Patients with uncontrolled diabetes, hematological malignancies, high-dose glucocorticoid therapy, iron overload, and organ transplantation are at high risk of acquiring mucormycosis. The second wave of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] affected India severely with the highest number of cases and deaths compared to all other countries. Additionally, the country was affected by emergence of rare but life-threatening mucormycosis. Currently, many coronavirus disease 2019 patients with underlying risk factors such as uncontrolled diabetes, high-dose steroid therapy, and exposure to mechanical ventilation have developed mucormycosis. Inhalation is the most common mode of transmission that results in colonization of sporangiospores in the nose. In immunocompromised host, sporangiospores germinate, and subsequently form hyphae. These hyphae invade into tissues, and produce tissue infarction, necrosis, and thrombosis. Angioinvasion causes hematogenous dissemination to many organs, predominantly to brain, that result in rhino-orbital-cerebral mucormycosis. Clinical characteristics, radio imaging, fungal culture, histopathology, and molecular techniques are the key diagnostic methods. Surgical intervention and aggressive antifungal therapy are the main management strategies. Amphotericin B is the drug of choice for treatment of mucormycosis, whereas posaconazole or isavuconazole is used for step-down therapy and salvage therapy.

Rare cause of ketolysis: Monocarboxylate transporter 1 deficiency

BACKGROUND

Monocarboxylate transporter 1 (MCT1) deficiency (MIM #616095) is a relatively new identified cause of recurrent ketoacidosis triggered by fasting or infections. MCT1 was first described in 2014 by van Hasselt et al. to result from both homozygous and heterozygous mutations in the SLC16A1 gene. Patients with homozygous mutations are known to have a more severe phenotype with developmental delay and epilepsy. Thirteen patients with MCT1 deficiency with ketoacidosis have been reported in the literature to date.

CASE

We describe a developmentally normal male patient with heterozygous missense variation in the SLC16A1 gene. Our patient who presented with cyclic vomiting and ketoacidosis episodes was found to have a heterozygous c.303T > G (p.Ile101Met) missense mutation.

CONCLUSIONS

It is crucial to take early preventive measures and to minimize the harmful effects of ketoacidotic episodes. MCT1 deficiency should be considered in the differential diagnosis of ketoacidosis in patients with normal SCOT and ACAT1 activities.