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Morand A, Barlogis V, Rouby F, Reynaud R, Marrec C, Michel G. [Hypertriglyceridemia, discovered on a pseudohyponatremia, induced by l-asparaginase in the treatment of B acute lymphoblastic leukemia in child]. Therapie 2023; 78:S91-S93. [PMID: 27771107 DOI: 10.2515/therapie/2015051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/15/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Aurélie Morand
- Oncologie pédiatrique, CHU Timone-Enfant, 13915 Marseille cedex 20, France.
| | - Vincent Barlogis
- Oncologie pédiatrique, CHU Timone-Enfant, 13915 Marseille cedex 20, France
| | - Frank Rouby
- Centre régional de pharmacovigilance et d'information sur les médicaments, hôpital Salvator, 13009 Marseille, France
| | - Rachel Reynaud
- Service d'hépato-gastro-entérologie et nutrition, endocrinologie et néphrologie pédiatriques, CHU Timone-Enfant, 13385 Marseille, France
| | - Céline Marrec
- Service d'hépato-gastro-entérologie et nutrition, endocrinologie et néphrologie pédiatriques, CHU Timone-Enfant, 13385 Marseille, France
| | - Gérard Michel
- Oncologie pédiatrique, CHU Timone-Enfant, 13915 Marseille cedex 20, France
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2
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Imburgio S, Vedire A, Sanekommu H, Johal A, Taj S, Lesniak C, Mushtaq A. Acute Pancreatitis as an Unusual Culprit of Diabetic Ketoacidosis in a Nondiabetic: A Case-Based Review. Case Rep Endocrinol 2023; 2023:9122669. [PMID: 37649470 PMCID: PMC10465251 DOI: 10.1155/2023/9122669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023] Open
Abstract
Acute pancreatitis has been associated with a multitude of complications including pancreatic necrosis, pseudocysts, abscesses, acute respiratory distress syndrome, disseminated intravascular coagulation, and hyperglycemia. To date, only rare case reports have demonstrated diabetic ketoacidosis (DKA) as a rare sequela of acute pancreatitis. We report a case of a 34-year-old female with no prior history of diabetes who was subsequently diagnosed with DKA after presenting with severe acute pancreatitis. This case serves as a framework to not only highlight DKA as a rare complication of acute pancreatitis but also to explore the potential pathophysiology that underlies this phenomenon including stress hyperglycemia and post-pancreatitis diabetes mellitus.
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Affiliation(s)
- Steven Imburgio
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, USA
| | - Apurva Vedire
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, USA
| | - Harshavardhan Sanekommu
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, USA
| | - Anmol Johal
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, USA
| | - Sobaan Taj
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, USA
| | - Christopher Lesniak
- Jersey Shore University Medical Center, Department of Endocrinology, 1945 NJ-33, Neptune City, NJ 07753, USA
| | - Arman Mushtaq
- Jersey Shore University Medical Center, Department of Endocrinology, 1945 NJ-33, Neptune City, NJ 07753, USA
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3
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Hirakuni Y, Itonaga T, Matsuda F, Maeda M, Ihara K. Diabetic lipemia as a predisposing state to acute pancreatitis: a case report and literature review. Diabetol Int 2023; 14:304-311. [PMID: 37397897 PMCID: PMC10307933 DOI: 10.1007/s13340-023-00630-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 04/03/2023] [Indexed: 07/04/2023]
Abstract
Hypertriglyceridemia has been recognized as a common complication of diabetes ketoacidosis (DKA), whereas severe hypertriglyceridemia, also known as diabetic lipemia, rarely occurs and is associated with an increasing risk of acute pancreatitis. We report the case of a 4-year-old girl with new-onset DKA associated with remarkable hypertriglyceridemia. Her serum triglyceride (TG) level was as high as 2490 mg/dL on admission and 11,072 mg/dL on day two during treatment with hydration and intravenous insulin infusion, whereas the critical situation was successfully stabilized by standard treatment for DKA without the occurrence of pancreatitis. We reviewed 27 cases of diabetic lipemia with or without pancreatitis that were described in the relevant literature to identify risk factors for the occurrence of pancreatitis in children with DKA. As a result, the severity of hypertriglyceridemia or ketoacidosis, age at onset, type of diabetes, and presence of systemic hypotension, were not associated with the development of pancreatitis; however, the occurrence of pancreatitis in girls over 10 years old tended to be higher than that in boys. The serum TG levels and DKA successfully normalized in most of the cases with insulin infusion therapy with hydration, without other specific treatments (e.g., heparin therapy and plasmapheresis). We conclude that the occurrence of acute pancreatitis in diabetic lipemia could be avoided with appropriate hydration and insulin therapy, without specific treatment for hypertriglyceridemia.
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Affiliation(s)
- Yuka Hirakuni
- Department of Pediatrics, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Yufu, Oita 879-5593 Japan
| | - Tomoyo Itonaga
- Department of Pediatrics, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Yufu, Oita 879-5593 Japan
| | - Fumika Matsuda
- Department of Pediatrics, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Yufu, Oita 879-5593 Japan
| | - Miwako Maeda
- Department of Pediatrics, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Yufu, Oita 879-5593 Japan
| | - Kenji Ihara
- Department of Pediatrics, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Yufu, Oita 879-5593 Japan
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Vitale RJ, Laffel LMB. New-Onset Type 1 Diabetes in a Child With Diabetic Ketoacidosis and Severe Hypertriglyceridemia Without Pancreatitis. JCEM CASE REPORTS 2023; 1:luad046. [PMID: 37223066 PMCID: PMC10201541 DOI: 10.1210/jcemcr/luad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Indexed: 05/25/2023]
Abstract
Hypertriglyceridemia is a complication of diabetic ketoacidosis (DKA) secondary to insulin deficiency inhibiting lipoprotein lipase and increasing lipolysis, but it is rare in children. A 7-year-old boy with history of autism spectrum disorder (ASD) presented with abdominal pain, vomiting, and "heavy breathing." Initial laboratory tests revealed pH 6.87 and glucose 385 mg/dL (21.4 mmol/L), consistent with new-onset diabetes and DKA. His blood appeared lipemic; triglycerides were 17 675 mg/dL (199.6 mmol/L) with normal lipase (10 units/L). He received intravenous insulin and DKA resolved within 24 hours. Insulin infusion continued through day 6 for management of hypertriglyceridemia; triglycerides decreased to 1290 mg/dL (14.6 mmol/L) during this period. He never developed pancreatitis (lipase peaked at 68 units/L) or required plasmapheresis. With his ASD history, he had a restrictive diet high in saturated fat, which included up to 30 breakfast sausages daily. His triglycerides normalized after discharge. Severe hypertriglyceridemia can complicate DKA in newly diagnosed type 1 diabetes (T1D). Hypertriglyceridemia can be safely managed with insulin infusion in the absence of end-organ dysfunction. This complication should be considered in patients with DKA at diagnosis of T1D.
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Affiliation(s)
- Rebecca J Vitale
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
- Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center, Boston, MA 02215, USA
- Division of Endocrinology, Department of Medicine, Brigham & Women's Hospital, Boston, MA 02115, USA
| | - Lori M B Laffel
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
- Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center, Boston, MA 02215, USA
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5
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Muacevic A, Adler JR, Abdallah S, Sokwala A. Plasma Exchange for the Treatment of Severe Hypertriglyceridemic Pancreatitis With Diabetic Ketoacidosis: A Case Report From Sub-Saharan Africa. Cureus 2022; 14:e31311. [PMID: 36514570 PMCID: PMC9735322 DOI: 10.7759/cureus.31311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
Abstract
The triad of acute pancreatitis, diabetic ketoacidosis, and hyperlipidemia is exceedingly rare. Case reports describing this uncommon triad have successfully been managed with insulin infusions only. Herein, we highlight the challenges in making this diagnosis and present Sub-Saharan Africa's first experience with therapeutic plasma exchange in the management of hypertriglyceridemic pancreatitis associated with diabetic ketoacidosis, which was initially refractory to insulin infusion alone.
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Park H, Kim MS, Kim J, Lee SM, Cho SY, Yoo EG, Jin DK. Hypertriglyceridemia with acute pancreatitis in a 14-year-old girl with diabetic ketoacidosis. Ann Pediatr Endocrinol Metab 2022; 27:73-77. [PMID: 34015902 PMCID: PMC8984753 DOI: 10.6065/apem.2040250.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/01/2021] [Indexed: 11/20/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a medically fatal condition in poorly controlled hyperglycemia or newly diagnosed diabetes mellitus. Severe hypertriglyceridemia (HTG) is an uncommon complication of DKA and can be associated with acute pancreatitis (AP). We present the clinical manifestations, laboratory findings, and management of AP associated with HTG in a 14-year-old girl with DKA. The patient, with a 7-year history of type 2 diabetes presented with epigastric pain, 1 month after stopping insulin injection. DKA, severe HTG, and AP were diagnosed based on the laboratory and imaging tests. She recovered from DKA after conventional treatment for DKA, and her triglyceride (TG) level was reduced from 10,867 mg/dL to the normal range after 7 days of admission without antilipid medication. Given that her C-peptide level was not too low and considering her negative diabetes-related antibodies and high TG level, targeted gene panel sequencing was performed on the genes associated with diabetes and HTG. We identified a heterozygous mutation, c.4607C>T (p. Ala1537Val), in ABCC8 related to maturityonset diabetes of the young (MODY) 12. To our knowledge, this is the first reported case of HTG-induced AP with DKA in a patient with MODY. In addition, we reviewed the literature for pediatric cases of HTG with DKA. In patients with DKA, timely awareness of severe HTG related to insulin deficiency is crucial for improving the consequences of AP. We recommend considering AP in all DKA patients presenting with severe HTG to ensure early and proper management.
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Affiliation(s)
- Hyojung Park
- Department of Pediatrics, Seongnam Citizens Medical Center, Seongnam, Korea
| | - Min-Sun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jiyeon Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sae-Mi Lee
- GC Genome, GCLabs, Yongin, Korea,Department of Laboratory Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung Yoon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea,Address for correspondence: Sung Yoon Cho Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Eun-Gyong Yoo
- Department of Pediatrics, College of Medicine, Pochon CHA University, Seongnam, Korea
| | - Dong-Kyu Jin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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8
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Grisham JM, Tran AH, Ellery K. Hypertriglyceridemia-induced acute pancreatitis in children: A mini-review. Front Pediatr 2022; 10:931336. [PMID: 36110119 PMCID: PMC9469503 DOI: 10.3389/fped.2022.931336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022] Open
Abstract
Severe hypertriglyceridemia (HTG) is a known metabolic cause of acute pancreatitis (AP) in pediatric patients. The incidence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is less well established in pediatric compared to adult patients. Studies in adults suggest that higher risk of AP occurs when triglyceride levels (TG) are >1,000 mg/dL. Most common etiologies for severe HTG in pediatric patients are either from primary hypertriglyceridemia, underlying genetic disorders of lipid and TG metabolism, or secondary hypertriglyceridemia, separate disease or exposure which affects TG metabolism. Most common theories for the pathophysiology of HTG-AP include hydrolysis of TG by pancreatic lipase to free fatty acids leading to endothelial and acinar cell damage and ischemia, as well as hyperviscosity related to increased chylomicrons. Though there are varying reports of HTG-AP severity compared to other causes of AP, a steadily growing body of evidence suggests that HTG-AP can be associated with more severe course and complications. Therapeutic interventions for HTG-AP typically involve inpatient management with dietary restriction, intravenous fluids, and insulin; select patients may require plasmapheresis. Long term interventions generally include dietary modification, weight management, control of secondary causes, and/or antihyperlipidemic medications. Though some therapeutic approaches and algorithms exist for adult patients, evidence-based management guidelines have not been well established for pediatric patients.
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Affiliation(s)
- John M Grisham
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, United States
| | - Andrew H Tran
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, The Ohio State University, Columbus, OH, United States
| | - Kate Ellery
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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Chreitah A, Hijazia K, Doya L, Salloum A. Severe dyslipidemia associated with diabetic ketoacidosis in newly diagnosed female of type 1 diabetes mellitus. Oxf Med Case Reports 2021; 2021:omab036. [PMID: 34729187 PMCID: PMC8557415 DOI: 10.1093/omcr/omab036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/13/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is considered as a serious complication of type 1 diabetes mellitus in pediatrics. Severe dyslipidemia in DKA is a rare eventuality. We report on a 10-year-old female presented with severe DKA. The serum was lipemic with severe hypertriglyceridemia and hypercholesterolemia. Laboratory workup: the values of glycemia, sodium and HbA1c were misleading; a method of dilution was used to obtain the correct values. Triglyceride and cholesterol returned gradually to normal levels only with the management of DKA without any complication. Mild dyslipidemia is a common feature in DKA, but severe dyslipidemia is a very rare event whose pathophysiology is not completely elucidated. It needs close surveillance because it might be responsible for acute pancreatitis and lipidemia retinalis.
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Affiliation(s)
- Ahmad Chreitah
- Department of Pediatric, Tishreen University Hospital, Lattakia, Syria
| | - Kheria Hijazia
- Department of Pediatric, Tishreen University Hospital, Lattakia, Syria
| | - Leen Doya
- Department of Pediatric, Tishreen University Hospital, Lattakia, Syria
| | - Alaa Salloum
- Department of Pediatric, Tishreen University Hospital, Lattakia, Syria
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Successful therapeutic plasma exchange in a case with extremely severe hypertriglyceridemia secondary to diabetic ketoacidosis concomitant with type IX glycogen storage disease. Transfus Apher Sci 2021; 61:103289. [PMID: 34690074 DOI: 10.1016/j.transci.2021.103289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 11/20/2022]
Abstract
Herein, we aimed to present a child with extremely severe hypertriglyceridemia (ESHTG) secondary to diabetic ketoacidosis concomitant with type IX glycogen storage disease (GSD). Extremely severe hypertriglyceridemia (10 700 mg/dL) was detected through the apparent lipemic appearance of the sampled blood in a 17-year-old male patient with severe diabetic ketoacidosis. In spite of insulin infusion, the patient's clinical condition deteriorated to acute pancreatitis. Single sessions of therapeutic plasma exchange (TPE) along with insulin treatment have successfully intercepted the progression of the state of acute pancreatitis. The patient was also diagnosed with type IX GSD on the basis of the genetic analyses performed for the potential underlying metabolic diseases. In conclusion, underlying metabolic diseases, such as glycogen storage disease, should be investigated in patients with diabetic ketoacidosis accompanied by severe hypertriglyceridemia. If ESHTG does not relieve despite insulin infusion, and/or acute pancreatitis occurs as a complication, TPE should be kept in mind.
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11
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Kravetz AM, Sanghavi P, Bhargava V, Shi RZ, Nally LM. Plasmapheresis as an Early Treatment for Severe Hypertriglyceridemia, Acute Pancreatitis, and Diabetic Ketoacidosis. AACE Clin Case Rep 2021; 7:315-319. [PMID: 34522772 PMCID: PMC8426612 DOI: 10.1016/j.aace.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023] Open
Abstract
Objective Severe hypertriglyceridemia (SHTG; plasma triglycerides >1000 mg/dL) is a rare but serious complication in children who develop diabetic ketoacidosis (DKA) from uncontrolled or new-onset type 1 diabetes. Methods We present the case of a severely malnourished 16-year-old with a 10-month history of presumed type 2 diabetes managed with lifestyle modifications and metformin, who presented with SHTG, acute pancreatitis, and DKA. On examination, there was no evidence of lipemia retinalis, cutaneous xanthomas, or xanthelasma. He was initially treated with an insulin infusion and intravenous fluids. Despite this treatment, his pancreatitis symptoms worseneed and lipase level increased, necessitating 2 courses of plasmapheresis that immediately resolved his symptoms and dramatically improved his clinical status. He was discharged on hospital day 5. During his hospital admission, islet cell antigen 512, insulin, glutamic acid decarboxylase 65, and zinc transporter 8 autoantibodies were positive in the presence of insulinopenia, consistent with type 1 diabetes. Results Hypertriglyceridemia and hypercholesterolemia did not recur during follow-up, suggesting that the underlying mechanism for SHTG was insulin deficiency. Conclusion This report of SHTG, DKA, and pancreatitis in an adolescent highlights the safe, early initiation of plasmapheresis as an effective treatment. To our knowledge, plasmapheresis has rarely been used so early in the course of treatment for an adolescent with SHTG, DKA, and acute pancreatitis.
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Affiliation(s)
- Ayesha Monga Kravetz
- Frank H. Netter MD School of Medicine, North Haven, Connecticut.,Department of Pediatrics, Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Pooja Sanghavi
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Vidit Bhargava
- Department of Pediatrics, Division of Pediatric Intensive Care, Stanford University School of Medicine, Stanford, California
| | - Run Zhang Shi
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Laura Marie Nally
- Department of Pediatrics, Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University School of Medicine, Stanford, California
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Tan TXZ, Lim SHC, Khoo J. Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus. BMJ Case Rep 2021; 14:14/8/e243696. [PMID: 34417241 PMCID: PMC8381315 DOI: 10.1136/bcr-2021-243696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 54-year-old woman with insulin-requiring type 2 diabetes mellitus presented with acute shortness of breath and drowsiness on a background of polydipsia, weakness and significant weight loss. One year ago, she had decided to stop her insulin and other medications and adopt lifestyle modifications instead. Initial emergency department (ED) blood samples were highly lipaemic and appeared strawberry pink. She was eventually diagnosed with diabetic ketoacidosis (DKA) with severe hypertriglyceridaemia, intubated for airway protection, and managed with fluid resuscitation and intravenous insulin to good effect. We share an uncommon DKA presentation at the ED. History was limited as the patient was drowsy and minimally communicative. Physical examination was unremarkable. Blood investigations were also delayed in view of the need for additional centrifugation. These contributed to a paucity of information in the acute setting and resulted in a diagnostic challenge.
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Affiliation(s)
| | | | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore
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Huang Z, Xu Z, Xu R, Huang L, Xu X, Lai X. Whole exome sequencing identifies three novel gene mutations in patients with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis. J Diabetes 2021; 13:200-210. [PMID: 32734598 DOI: 10.1111/1753-0407.13100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/05/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This study aimed to analyze the genetics and treatments of the patients with the triad of diabetic ketoacidosis (DKA), hypertriglyceridemia, and acute pancreatitis (AP). METHODS We conducted a retrospective study of six patients with the triad of AP, hypertriglyceridemia, and DKA at our hospital. All patients underwent plasmapheresis as part of their treatment. The clinical characteristics of the patients were obtained from the hospital information system and analyzed. Whole exome sequencing was performed using samples of one patient (case 6) and his family members. RESULTS The average triglyceride level before plasmapheresis was 3282.17 ± 2975.43 mg/dL (range: 1646-9332 mg/dL). The triglyceride levels dropped by approximately 80% after plasmapheresis. None of the patients developed complications related from plasmapheresis. During follow-up, patients 5 and 6 developed recurrent pancreatitis for several times and showed the formation of pancreatic pseudocysts. We identified three novel heterozygous missense mutations in the family of patient 6, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD. CONCLUSIONS Three novel heterozygous missense mutations, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD were first identified in a patient with the triad of DKA, hypertriglyceridemia, and AP. The combination of plasmapheresis, hydration, and insulin therapy may have the greatest clinical benefits for these patients.
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Affiliation(s)
- Zixi Huang
- Department of General Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyan Xu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ruoqing Xu
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Huang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiang Xu
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoyang Lai
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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14
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Dai J, Jiang M, Hu Y, Xiao J, Hu B, Xu J, Han X, Shen S, Li B, Wu Z, He Y, Ren Y, Wen L, Wang X, Hu G. Dysregulated SREBP1c/miR-153 signaling induced by hypertriglyceridemia worsens acute pancreatitis and delays tissue repair. JCI Insight 2021; 6:138584. [PMID: 33491670 PMCID: PMC7934861 DOI: 10.1172/jci.insight.138584] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 12/02/2020] [Indexed: 01/01/2023] Open
Abstract
Severe acute pancreatitis (AP) is a life-threatening disease with up to 30% mortality. Therefore, prevention of AP aggravation and promotion of pancreatic regeneration are critical during the course and treatment of AP. Hypertriglyceridemia (HTG) is an established aggravating factor for AP that hinders pancreatic regeneration; however, its exact mechanism remains unclear. Using miRNA sequencing and further verification, we found that miRNA-153 (miR-153) was upregulated in the pancreas of HTG animal models and in the plasma of patients with HTG-AP. Increased miR-153 aggravated HTG-AP and delayed pancreatic repair via targeting TRAF3. Furthermore, miR-153 was transcriptionally suppressed by sterol regulatory element-binding transcription factor 1c (SREBP1c), which was suppressed by lipoprotein lipase malfunction-induced HTG. Overexpressing SREBP1c suppressed miR-153 expression, alleviated the severity of AP, and facilitated tissue regeneration in vivo. Finally, therapeutic administration of insulin also protected against HTG-AP via upregulating SREBP1c. Collectively, our results not only provide evidence that HTG leads to the development of more severe AP and hinders pancreatic regeneration via inducing persistent dysregulation of SREBP1c/miR-153 signaling, but also demonstrate that SREBP1c activators, including insulin, might be used to treat HTG-AP in patients.
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Affiliation(s)
- Juanjuan Dai
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mingjie Jiang
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yangyang Hu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jingbo Xiao
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Hu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiyao Xu
- Department of Emergency, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Han
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuangjun Shen
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Li
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zengkai Wu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan He
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yingchun Ren
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li Wen
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingpeng Wang
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guoyong Hu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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15
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Novak C, Johnson S, Rinholm G, Foulds J. A 4 year-old Girl with Diabetic Ketoacidosis and Lipemic Blood. Pediatr Rev 2020; 41:S89-S90. [PMID: 33004593 DOI: 10.1542/pir.2018-0279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Graeme Rinholm
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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16
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Abstract
OBJECTIVES Hypertriglyceridemia-induced pancreatitis is an important cause of acute pancreatitis (AP) in children, which lacks established guidelines. The aim of this study was to review management approaches at a single pediatric center. METHODS This retrospective study included all inpatients younger than 21 years with AP and triglycerides (TG) of 1000 mg/dL or greater. A linear mixed effect model was used to calculate drop in TGs. The patient's diet, intravenous fluid (IVF) rate, insulin, and plasmapheresis were included in the model. RESULTS Seventeen admissions were identified among 8 patients, average age 15 years (range, 6-19 years). Fifty percent had recurrent AP and 29% of admissions had complications including 1 death. The population was primarily female (75%), white (75%), and overweight, and 63% had diabetes. The median stay was 5.4 days. There were 14 approaches used with variations in IVF rates, insulin, plasmapheresis, and nill per os (NPO) versus feeds. Variables that reduced TG's were NPO, higher IVF rates, plasmapheresis, and insulin (P < 0.05). Importantly, NPO reduced TGs faster than those who started early nutrition. CONCLUSIONS Hypertriglyceridemia is an important cause of pancreatitis in children. This study shares a management algorithm from a single institution. Larger studies are needed for more evidence-based guidelines.
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17
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Poon S, Leung K, Tung J. Management of severe hypertriglyceridemia due to lipoprotein lipase deficiency in children. Endocrinol Diabetes Metab Case Rep 2019; 2019:1-5. [PMID: 31352695 PMCID: PMC6685095 DOI: 10.1530/edm-19-0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Summary Severe hypertriglyceridemia is an endocrine emergency and is associated with acute pancreatitis and hyperviscosity syndrome. We describe an infant with lipoprotein lipase deficiency with severe hypertriglyceridemia who presented with acute pancreatitis. She was managed acutely with fasting and intravenous insulin infusion, followed by low-fat diet with no pharmacological agent. Subsequent follow-up until the age of 5 years showed satisfactory lipid profile and she has normal growth and development. Learning Points Hypertriglyceridemia-induced acute pancreatitis has significant morbidity and mortality, and prompt treatment is imperative.
When no secondary causes are readily identified, genetic evaluation should be pursued in hypertriglyceridemia in children.
Intravenous insulin is a safe and effective acute treatment for hypertriglyceridemia in children, even in infants.
Long-term management with dietary modifications alone could be effective for primary hypertriglyceridemia due to lipoprotein lipase deficiency, at least in early childhood phase.
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Affiliation(s)
- Sarah Poon
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Karen Leung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Joanna Tung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
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18
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Yagnik PJ, Desai PH, Modem VM. Hypertriglyceridemia with Acute Pancreatitis in Pediatric Diabetic Ketoacidosis: A Case Report. Cureus 2019; 11:e3844. [PMID: 30891384 PMCID: PMC6411334 DOI: 10.7759/cureus.3844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 16-year-old female with new-onset diabetic ketoacidosis (DKA) developed acute pancreatitis and hypertriglyceridemia within 24 hours after admission. Her insulin regimen was continued after resolution of DKA, and her pancreatitis with hypertriglyceridemia showed resolution. We are presenting a case of pediatric DKA with hypertriglyceridemia and pancreatitis treated with extended insulin.
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Affiliation(s)
- Priyank J Yagnik
- Pediatrics, University of Kansas School of Medicine - Wichita, Wichita, USA
| | - Pooja H Desai
- Pediatrics, University of Kansas School of Medicine - Wichita, Wichita, USA
| | - Vinai M Modem
- Pediatrics, University of Texas Health Science Center at Houston, Frisco, USA
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19
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Diabetic Ketoacidosis Revealing a Severe Hypertriglyceridemia and Acute Pancreatitis in Type 1 Diabetes Mellitus. Case Rep Endocrinol 2019; 2019:8974619. [PMID: 30723557 PMCID: PMC6339756 DOI: 10.1155/2019/8974619] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/01/2018] [Accepted: 12/26/2018] [Indexed: 11/17/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication occurring in patients with diabetes, especially in patients with type 1 diabetes (T1D), due to an insulin deficiency. Moderate hypertriglyceridemia is commonly observed in DKA but severe hypertriglyceridemia with a triglyceride level exceeding 10g/L is very rarely reported. We report a case of a 14-year-old boy who had type 1 diabetes for 4 years treated with insulin therapy, also having adrenal insufficiency treated with hydrocortisone who presented with ketoacidosis and excruciating abdominal pain. Investigations revealed hypertriglyceridemia at 64g/L, lipasemia at 1000 U/L, and stage E pancreatitis on abdominal CT. The patient was treated with intravenous insulin, rehydration, and fenofibrate with good clinical and biological evolution. Severe hypertriglyceridemia causing pancreatitis in type 1 diabetes mellitus is a rare but very serious complication of DKA in children.
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20
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 344] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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21
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McKelvie B, Stein R. A lipemic blood sample in the paediatric critical care unit. Paediatr Child Health 2018; 24:10-11. [PMID: 30792592 DOI: 10.1093/pch/pxy086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brianna McKelvie
- Department of Paediatrics, Children's Hospital at London Health Sciences Centre, London, Ontario
| | - Robert Stein
- Department of Paediatrics, Children's Hospital at London Health Sciences Centre, London, Ontario
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22
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Concurrent Diabetic Ketoacidosis in Hypertriglyceridemia-Induced Pancreatitis: How Does It Affect the Clinical Course and Severity Scores? Pancreas 2017; 46:1336-1340. [PMID: 28984788 DOI: 10.1097/mpa.0000000000000937] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Concurrent diabetic ketoacidosis (DKA) is highly prevalent in patients with hypertriglyceridemia-induced pancreatitis (HP). Diabetic ketoacidosis could potentially complicate the diagnosis, management, and prognosis of HP. This study aimed to directly compare the clinical course of HP with and without DKA and assess the outcomes of frequently used severity-prediction scores in such population. METHODS We retrospectively analyzed 140 patients with HP; 37 patients (26.4%) had concurrent DKA. We compared epidemiologic characteristics, initial laboratory values, and clinical courses between the DKA and non-DKA groups. Bedside Index for Severity in Acute Pancreatitis score, Sequential Organ Failure Assessment score, Ranson criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Marshall score were calculated and compared between groups. RESULTS We observed more acute kidney injury in the DKA group. Patients with DKA more likely required intensive care unit admission, received intravenous insulin, and were discharged on subcutaneous insulin. Ranson criteria and APACHE II score were significantly higher with DKA. CONCLUSIONS Concurrent DKA does not affect length of stay, in-hospital mortality, and readmission rate in patients with HP. Higher Ranson criteria and APACHE II score likely reflected derangement of clinical parameters secondary to DKA rather than true severity of pancreatitis in such population.
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23
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Plasmapheresis for Hypertriglyceridemia-Induced Acute Pancreatitis in a Child: A Case Report and Brief Review of the Literature. Pancreas 2017; 46:e58-e59. [PMID: 28697142 DOI: 10.1097/mpa.0000000000000855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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24
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Bär S, Daudel F, Zueger T. Ominous triad triggered by high-dose glucocorticosteroid therapy. BMJ Case Rep 2017. [PMID: 28630246 DOI: 10.1136/bcr-2017-220328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Glucocorticosteroids (CS) play a key role in the treatment of numerous diseases. Nonetheless, they can be accompanied by several adverse effects. We present the case of a 51-year-old woman who was treated with high-dose CS for a relapse of her multiple sclerosis. After 5 days of treatment, the patient developed severe diabetic ketoacidosis, hypertriglyceridemia and acute pancreatitis-a potentially life-threatening triad which has previously been described, in our case, however, for the first time as a complication of CS therapy. Our patient's condition was further aggravated by a circulatory shock, haemodynamic relevant bleeding from a duodenal ulcer and psychotic symptoms. In the intensive care unit, intravenous insulin infusion, fluid resuscitation, catecholamine support, electrolyte supplementation, endoscopic haemoclipping and antibiotic and antipsychotic treatment were administered, leading to a continuous improvement of the patient's health state.
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Affiliation(s)
- Sarah Bär
- Division of Internal Medicine, Hospital Tiefenau, Inselgruppe AG, University of Bern, Bern, Switzerland
| | - Fritz Daudel
- Division of Intensive Care, Hospital Tiefenau, Inselgruppe AG, University of Bern, Bern, Switzerland
| | - Thomas Zueger
- Division of Internal Medicine, Hospital Tiefenau, Inselgruppe AG, University of Bern, Bern, Switzerland
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25
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Wang Y, Attar BM, Bedrose S, Trick W, Rivas-Chicas O, Simons-Linares CR, Onyenwenyi C, Siddamesetti S, Fogelfeld L. Diabetic Ketoacidosis With Hypertriglyceridemia-Induced Acute Pancreatitis As First Presentation Of Diabetes Mellitus: Report Of Three Cases. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161389.cr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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26
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Sharma PK, Kumar M, Yadav DK. Severe Hypertriglyceridemia Causing Pancreatitis in a Child with New-onset Type-I Diabetes Mellitus Presenting with Diabetic Ketoacidosis. Indian J Crit Care Med 2017; 21:176-178. [PMID: 28400692 PMCID: PMC5363110 DOI: 10.4103/ijccm.ijccm_281_16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The triad of pancreatitis, hypertriglyceridemia, and diabetic ketoacidosis and its treatment has not been extensively discussed in the pediatric literature. We report a 4-year-old child with severe hypertriglyceridemia, pancreatitis, and diabetic ketoacidosis. Hypertriglyceridemia and pancreatitis with diabetic ketoacidosis can be successfully managed with insulin and hydration therapy in children. Early recognition of this triad is important as insulin requirements, recovery duration, and prognosis can be altered.
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Affiliation(s)
- Pradeep Kumar Sharma
- Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action Medical Institute, New Delhi, India
| | - Maneesh Kumar
- Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action Medical Institute, New Delhi, India
| | - Dinesh Kumar Yadav
- Department of Clinical Biochemistry, Sri Balaji Action Medical Institute, New Delhi, India
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27
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Toxic-metabolic Risk Factors in Pediatric Pancreatitis: Recommendations for Diagnosis, Management, and Future Research. J Pediatr Gastroenterol Nutr 2016; 62:609-17. [PMID: 26594832 PMCID: PMC4805437 DOI: 10.1097/mpg.0000000000001035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatitis in children can result from metabolic and toxic risk factors, but the evidence linking these factors is sparse. We review the evidence for association or causality of these risk factors in pancreatitis, discuss management strategies, and their rationale. We conducted a review of the pediatric pancreatitis literature with respect to the following risk factors: hyperlipidemia, hypercalcemia, chronic renal failure, smoking exposure, alcohol, and medications. Areas of additional research were identified. Hypertriglyceridemia of 1000 mg/dL or greater poses an absolute risk for pancreatitis; persistent elevations of calcium are predisposing. Further research is necessary to determine whether end-stage renal disease leads to increased pancreatitis in children similar to adults. It is unknown whether cigarette smoking exposure, which clearly increases risk in adults, also increases risk in children. The role of alcohol in pediatric pancreatitis, whether direct or modifying, needs to be elucidated. The evidence supporting most cases of medication-induced pancreatitis is poor. Drug structure, improper handling of drug by host, and bystander status may be implicated. Other pancreatitis risk factors must be sought in all cases. The quality of evidence supporting causative role of various toxic and metabolic factors in pediatric pancreatitis is variable. Careful phenotyping is essential, including search for other etiologic risk factors. Directed therapy includes correction/removal of any agent identified, and general supportive measures. Further research is necessary to improve our understanding of these pancreatitis risk factors in children.
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28
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DKA with Severe Hypertriglyceridemia and Cerebral Edema in an Adolescent Boy: A Case Study and Review of the Literature. Case Rep Endocrinol 2016; 2016:7515721. [PMID: 26904318 PMCID: PMC4745619 DOI: 10.1155/2016/7515721] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/04/2016] [Indexed: 11/17/2022] Open
Abstract
A 13-year-old adolescent boy with type 1 diabetes mellitus (1b) presented with diabetic ketoacidosis (DKA) and cerebral edema. Grossly lipemic serum and lipemia retinals due to extremely high triglyceride (TG) level were observed without evidence of xanthoma or xanthelasma. Cerebral edema was treated by appropriate ventilation and mannitol administration. Normal saline was carefully given and regular insulin was titrated according to blood sugar levels. Triglyceride levels were reduced from 9,800 mg/dL to normal range within 9 days after conventional treatment was commenced without antilipid medication. Based on our review of the literature, this is the first reported case of confirmed pediatric DKA with severe hypertriglyceridemia and cerebral edema. In patients with DKA and hypertriglyceridemia, clinicians should be mindful of the possibility of associated acute pancreatitis and cerebral edema.
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29
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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30
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Seda G, Meyer JM, Amundson DE, Daheshia M. Plasmapheresis in the management of severe hypertriglyceridemia. Crit Care Nurse 2014; 33:18-23; quiz 24. [PMID: 23908166 DOI: 10.4037/ccn2013346] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Plasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis.
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Affiliation(s)
- Gilbert Seda
- Medical Corps, US Navy, Department of Pulmonary and Critical Care Medicine, Naval Medical Center San Diego, San Diego, California, USA.
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31
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[Plasmapheresis in the treatment of an acute pancreatitis due to hypertriglyceridemia]. Med Clin (Barc) 2013; 142:282. [PMID: 24315744 DOI: 10.1016/j.medcli.2013.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 01/04/2023]
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32
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Denecker N, Decochez K. Poorly controlled type 2 diabetes complicated by an episode of severe hypertriglyceridaemia-induced pancreatitis. BMJ Case Rep 2013; 2013:bcr-2012-008455. [PMID: 23632173 DOI: 10.1136/bcr-2012-008455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A 23-year-old woman with a history of type 2 diabetes and non-compliance presented to the emergency department with abdominal epigastric pain and nausea. Laboratory examination revealed a mild ketoacidosis while an abdominal CT scan performed the following day demonstrated a severe acute pancreatitis of the body and tail (Balthazar grade E) despite normal amylase serum levels on admission. The presence of a lactescent serum was the clue to an extremely high triglyceride level (>10 000 mg/dl) causing the pancreatitis. The hypertriglyceridaemia itself was attributed mainly to the diabetic ketoacidosis. There was no family history of hypertriglyceridaemia. The triad consisting of diabetic ketoacidosis, hypertriglyceridaemia and acute pancreatitis is an unusual presentation of poorly controlled diabetes which can occur in type 1 as well as type 2 diabetic adults and children. Treatment with intravenous insulin and hydration successfully resolved the ketoacidosis and hypertriglyceridaemia and reversed the episode of acute pancreatitis.
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Affiliation(s)
- Nathalie Denecker
- Department of Endocrinology-Diabetes, UZ Brussel, Brussels, Belgium.
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