sodes of hyperglycemia . 1-4 The endocrine response to the destruction of pancreatic tissue includes a loss of pancreatic islet cells , including alpha , beta , and pancreatic polypeptide ( PP ) cells , leading to decreased pancreatic peptide secretion . The destruction also decreases glucagon secretion , yielding liable or brittle blood sugars as well as a decrease in insulin receptors on hepatic cells . The result is gluconeogenesis that causes hyperglycemia . 2 The key feature that distinguishes type 3c from types 1 and 2 is the unstable blood glucose control due to the loss of the glucagon response to hypoglycemia ( endocrine ) and carbohydrate malabsorption ( exocrine ) ( Table 3 ). 2
Our patient had an initial HbA1c of 5.6 %, which increased to 8.1 % with progression of his pancreatitis . He was given adequate fluid resuscitation and only required small doses of insulin to lower his hyperglycemia to an acceptable range . He met the criteria to be diagnosed with diabetes ; however , our patient was unlike patients with newly diagnosed type 2 diabetes who require higher insulin requirements and / or continuous intravenous infusion of insulin .
Differentiating type 3c diabetes from type 1 or type 2 diabetes is not always straightforward ( Table 3-Table 6 ). Destruction of the islet cells by pancreatic inflammation differs from that in type 1 diabetes , as there is also a loss of glucagon and PP from the islet alpha cells and PP cells ( as well as the loss of insulin from the islet beta-cells ). Additionally , nutrient malabsorption leads to impaired incretin secretion and therefore diminished release from the remaining beta cells . According to the diagnostic criteria developed by Ewald and Hardy , 2 our patient met the criteria for type 3c diabetes with exocrine insufficiency as evidenced by his severely low stool pancreatic elastase and an MRI sowing pancreatic inflammation . Further solidifying this diagnosis were the patient ’ s laboratory findings , specifically the low c-peptide , low PP , and deficiencies of fat-soluble vitamins . Tables 4 and 5 highlight laboratory differences and clinical differences between type 2 and type 3c diabetes respectively .
Treatment in our patient began with a focus on exocrine deficiency , and pancreatic en-
TABLE 1 . Patient Laboratory Values Upon Presentation to Emergency Department Test / Marker Patient Value Normal Reference Range bilirubin , conjugated 0.4 mg / dL < 0.3 mg / dL aspartate aminotransferase 22 U / L 8 - 48 U / L alanine transaminase 29 U / L < 55 U / L alkaline phosphatase 121 U / L < 150 U / L gamma-glutamyl transferase 299 U / L 7 - 50 U / L lipase 249 U / L 10 - 80 U / L serum pH 7.43 U / L 7.31 - 7.41 U / L
PCO 2
39 mm / Hg 41.00 - 51.00 mm / Hg
PO 2
34.0 mm / Hg 35.0 - 50.0 mm / Hg white blood cells 12.8 x10^3 / uL 3.5 - 11.0 x10ˆ3 / uL hemoglobin 17.3 g / dL 12.5 - 16.3 g / dL hematocrit 50.0 % 36.7 - 47.0 % platelet count 263 x10^3 / uL 140 - 450 x10ˆ3 / uL sodium 130 mmol / L 136 - 145 mmol / L potassium 3.7 mmol / L 3.5 - 5.1 mmol / L chloride 94 mmol / L 96 - 111 mmol / L carbon dioxide 25 mmol / L 22 - 32 mmol / L blood urea nitrogen 9 mg / dL 8 – 25 mg / dL creatinine 1.17 mg / dL 0.62 - 1.27 mg / dL glucose 577 mg / dL 65 - 139 mg / dL calcium 9.1 mg / dL 8.5 - 10.2 mg / dL
mg / dL : milligram per deciliter , U / L : units per Liter , mm / Hg : millimeter of mercury , uL : microliter , mmol / L : millimole per liter ; PC02 : partial pressure of carbon dioxide , P02 : partial pressure of oxygen
TABLE 2 . Patient Laboratory Values Upon Further Pancreatic Assessment
Test / Marker Patient Value Normal Reference Range calprotectin , feces < 15.6 mcg / g <= 50.0 mcg / g immunoglobulin subclass IgG4 36.9 mg / dL 2.4 - 121.0 mg / dL pancreatic polypeptide , plasma 79 pg / mL < 291 pg / mL C-peptide 0.6 ng / mL 0.9 - 7.1 ng / mL vitamin D 25 TOTAL < 7 ng / mL 30 - 100 ng / mL vitamin E 6.8 mg / L 5.0 - 18.0 mg / L vitamin K < 0.10 ng / mL 0.10 - 2.20 ng / mL vitamin A , serum 21.9 mcg / dL 32.5 - 78.0 mcg / dL hemoglobin A1c 8.1 % < 5.7 % pancreatic elastase , feces 53 mcg / g > 200 mcg / g
mcg / g : microgram per gram , mg / dL : milligram per deciliter , pg / mL : pictograms per milliliter , ng / mL : nanograms per milliliter , mg / L : milligrams per liter
West Virginia Medical Journal • June 2021 • 37