Diabetic ketoacidosis accompanied by hypothermia: a case report

Prominent black esophagus, Wischnewsky spots, and black duodenum in a fatal hypothermia case with an underlying diabetic ketoacidosis

Hypothermia can occur in patients with diabetic ketoacidosis (DKA), and these two conditions can exacerbate each other. Fatal hypothermia and DKA have overlapping features and findings such as Wischnewsky spots (WS), black esophagus, basal subnuclear vacuolization in the renal tubule, dehydration, and increased acetone levels. Therefore, it may be challenging to differentiate or clarify the context of these two conditions. Herein, we report a case of a 49-year-old man with type 1 diabetes who was found lying in his house in mid-winter. He experienced cardiopulmonary arrest 10 h after the initial discovery and died at the hospital. On autopsy, florid left cardiac blood was observed. Black discoloration of the distal part of the esophageal mucosa, widespread WS in the gastric mucosa, and black discoloration of the duodenal mucosa were observed. Histologically, neutrophil infiltration in the esophageal mucosa, neutrophil infiltration and bleeding in the gastric mucosa, basal subnuclear vacuolization and Armanni-Ebstein lesion in the renal tubule epithelium in the kidney, and hyalinization of the islets of Langerhans were observed in the pancreas. Blood acetone and β-hydroxybutyrate levels were 538 µg/mL and 8947 µmol/L, respectively. Glycated hemoglobin A1c and glucose levels were 16.2% and 883 mg/dL, respectively, while C-reactive protein level was 3.64 mg/dL. In conclusion, obnubilation due to DKA was assumed to be the underlying cause of hypothermia, and the combination of these two conditions led to the outcome of death. The concurrent presence of these conditions likely contributed to the conspicuous mucosal findings in the upper gastrointestinal tract.

Brief Report: Diabetic Keto-Acidosis (DKA) Induced Hypothermia may be Neuroprotective in Cardiac Arrest

Despite the decreased survival associated with diabetes with out-of-hospital cardiac arrest and the overall low survival to hospital discharge, we would like to present two cases of OHCA in diabetics who despite prolonged resuscitation efforts had complete neurological recovery likely due to concomitant hypothermia. There is a steady decreasing rate of ROSC with longer durations of CPR so that outcomes are best when <20 minutes compared to prolonged resuscitation efforts (>30-40 minutes). It has been previously recognized that hypothermia prior to cardiac arrest can be neurologically protective even with up to 9 hours of cardiopulmonary resuscitation. Hypothermia has been associated with DKA and although often indicates sepsis with mortality rates of 30-60%, it may indeed be protective if occurring prior to cardiac arrest. The critical factor for neuroprotection may be a slow drop to a temperature <25⁰C prior to OHCA as is achieved in deep hypothermic circulatory arrest for operative procedures of the aortic arch and great vessels. It may be worthwhile continuing aggressive resuscitation efforts even for prolonged periods before attaining ROSC for OHCA in patients found hypothermic from metabolic illnesses as compared to only from environmental exposures (avalanche victims, cold water submersions, etc.) as has been traditionally reported in the medical literature.

Hyperketonemia as the diagnostic basis for hypothermia: An experimental study in diabetic and control mice

Hypothermia is an important cause of death in forensic pathology. For the forensic diagnosis of hypothermia, some reports point out the possibility that hypothermia without diabetes may cause ketoacidosis. In this study, we evaluated the diagnostic value of ketoacidosis in a murine model of hypothermia, using the cold stress at 4 °C for 3 or 5 hrs in genetically diabetic (BKS.Cg-+Lepr^db/+Lepr^db/J) mice, compared with control (BKS.Cg- Dock7^m+/Dock7^m+/J) mice. The core temperature decrease was larger in diabetic mice than in control mice. We observed a novel finding that ketoacidosis assessed by elevated serum 3-hydroxybutyrate (3HB) occurs in hypothermia both in diabetic and control mice. Diabetic mice showed a prominent elevation of serum 3HB under cold stress. The protein expressions of monocarboxylate cotransporter 1 (MCT1), the channel protein used for the uptake of 3HB in skeletal muscles, showed a statistically significant decrease under cold stress for 3 hrs in control mice, indicating that the serum 3HB increase may be partially due to the decrease in the cellular uptake through the channel protein. Our results suggest the usefulness of hyperketonemia for the diagnosis of hypothermia not only in diabetic but also in non-diabetic cases.

Coronary artery bypass grafting: a precipitating factor for perioperative diabetic ketoacidosis

Non-Insulin Dependent Diabetes Mellitus (NIDDM) is a common disease entity in patients with Coronary Artery Disease (CAD). Diabetic Ketoacidosis (DKA) is not only one of the major complications of Diabetes Mellitus but also a significant challenging clinical entity for the patients undergoing any elective or emergency surgery. Coronary Artery Bypass Grafting (CABG) being done in a patient with DKA has not been reported. We are presenting a rare case with DKA in whom CABG was carried out in a hospital devoted exclusively to cardiac cases. Insulin was given in very large doses as a part of therapeutic regimen and the outcome was favorable. This report concludes that if a patient undergoing urgent cardiac surgery incidentally develops DKA after induction of anesthesia, then the operation can be carried out provided DKA is managed aggressively. Also, major stress factors like cardio pulmonary bypass (CPB) and hypothermia should be avoided and care should be taken to avoid cerebral edema.