Diabetic Ketoacidosis and the Domino Effect

Diabetic Ketoacidosis-Induced "Terrible Triad" Associated With Seizures and Acute Renal Failure: A Report of a Rare Case

We report a case of a 17-year-old male patient who came to the emergency department with abdominal pain, headaches for two days, lethargy, and Kussmaul breathing. Diabetic ketoacidosis (DKA) was diagnosed. The patient's clinical course was complicated with a severely elevated triglyceride (TG) level (25,585 mg/dL), acute pancreatitis, renal involvement, and generalized seizures. The proposed mechanism is triglyceride excess due to increased lipolysis, resulting in the formation of excess free fatty acids. The objective of this case report is to present and describe the clinical features, laboratory investigations, case management, and natural course of hypertriglyceridemia in DKA.

Severe hypertriglyceridemia: A rare complication of diabetic ketoacidosis in a 3-year-old with SARS-CoV-2 infection

INTRODUCTION

Children commonly present in diabetic ketoacidosis (DKA) secondary to Type 1 diabetes mellitus. Electrolyte imbalances and cerebral edema are common complications in the pediatric age group; however, patients may also have additional metabolic disturbances such as hyperlipidemia. We report a case of a pediatric patient with new-onset type 1 Diabetes Mellitus (DM) and DKA complicated by severe hypertriglyceridemia with recent exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

CASE PRESENTATION

A three-year-old male noted to be SARS-CoV-2 positive, presented with hyperglycemia, metabolic acidosis, and ketosis consistent with DKA. Patient was later found to have severe hypertriglyceridemia (greater than 5680 mg/dL). He was managed with intravenous (IV) fluids and IV insulin replacement with improvement of triglycerides.

CONCLUSION

Severe hypertriglyceridemia in DKA, though rare in the pediatric population, responds very well to IV insulin therapy. This case also highlights possible need for early lipid screening in DKA patients with SARS-CoV-2 positive status.

An Unusual Case of the "Terrible Triad" in a Transgender Woman

With the increasing use of sodium-glucose cotransporter-2 inhibitors for type 2 diabetes and heart failure, clinicians need to understand how to treat euglycemic diabetic ketoacidosis (DKA), which is a potential side effect of the medication. The disease triad of euglycemic ketoacidosis, acute pancreatitis, and hypertriglyceridemia (HTG) has complex pathogenesis, and often the trigger of the triad is unknown. Here, we present an unusual case of euglycemic DKA in a transitioning transgender woman on canagliflozin who was treated with 10% dextrose and insulin infusions and apheresis. What makes our case unique is an added layer of complexity with her use of estrogen supplements contributing to HTG and gallstone formation, which could have set off the disease triad.