SCIENTIFIC
A Patient with Type 3c Diabetes Mellitus Presenting in Ketoacidosis Following Acute Necrotizing Pancreatitis
AUTHORS: Nicholas Miller, BS Robert Levi Snedegar, MD Sylwia Brooks, MD, PhD
AFFILIATIONS: Department of Family Medicine
West Virginia University School of Medicine
CORRESPONDING AUTHOR: Robert Levi Snedegar, MD
DISCLOSURES: None
ETHICS STATEMENT: Permission obtained from patient
FUNDING: None
CASE REPORT
A 36-year-old woman with a past medical history of severe alcohol use disorder and hypertension presented to the emergency department with nausea, vomiting, and right upper quadrant abdominal pain. At admission, she was still taking antibiotics and steroids for colitis treatment. Initial workup was suggestive of acute pancreatitis suspected to be secondary to alcohol consumption with laboratory studies revealing the following results: lipase 409 U / L( later peaking at > 1700 U / L), ethanol level 105 mg / dL, aspartate transaminase 62 U / L, and alanine transaminase 39 U / L. Computed tomography( CT) scan of the abdomen and pelvis with intravenous( IV) contrast was consistent with acute pancreatitis and mild ascending / cecal colitis. Pancreatitis was treated following recommended fluid resuscitation protocol as well as aggressive pain management regimen and early parenteral refeeding. 1 The steroids were stopped while the patient continued to receive antibiotics for colitis. Her alcohol withdrawal symptoms were monitored and
ABSTRACT
INTRODUCTION
treated with lorazepam dosed as needed. The patient’ s symptoms improved while on antibiotics and she was tolerating oral nutrition. During her hospital stay, her blood glucose levels remained elevated in 200-300 mg / dL range. Given that her hemoglobin A1c on admission was 5.5 % this hyperglycemia was thought to be secondary to steroid treatment prior to admission as well as cortisol-induced stress response from the acute illness. She was treated with sliding scale insulin. On day two of hospitalization, she developed a cough and her chest radiograph was concerning for pneumonia; her antibiotics were adjusted to treat pneumonia as well as colitis. The patient was deemed stable for discharge on day three of hospitalization. She was discharged with antibiotics for pneumonia and colitis and analgesics for pancreatitis.
On post-discharge day six, the patient returned to the emergency department with altered mental status, nausea, and vomiting. At the time of presentation, her blood glucose was 718 mg / dL, venous blood gas revealed a pH of 6.89 with lactate of 3. 4 mmol / L, anion gap 17 mEq / L, bicarbonate < 5 mEq / L, and beta-hydroxybutyrate 12.6 mmol / L. Computed tomography( CT) scan of the abdomen and pelvis( Figure 1) showed interval worsening of pancreatitis with evidence of necrosis in the pancreatic head, body, and tail. The patient was diagnosed with diabetic ketoacidosis( DKA) and treated appropriately per West Virginia University hospitals’ institutional protocol. During this hospitalization, she
Type 3c or pancreatogenic diabetes mellitus( DM) refers to diabetes associated with disease of the exocrine pancreas such as pancreatitis, cystic fibrosis, or hemochromatosis. It is very commonly misdiagnosed as type 2 DM. We present a case of a 36-year-old female who presented in diabetic ketoacidosis secondary to untreated type 3c DM following an episode of severe acute necrotizing pancreatitis. To our knowledge, this is the first reported case of type 3c DM due to acute necrotizing pancreatitis presenting in this manner. This case demonstrates the need for prompt recognition and early management of type 3c DM among patients affected by pancreatic pathologies as well as the need for consideration of discharge with home diabetic testing supplies of patients with acute pancreatitis.
received extensive diabetic education, started basal insulin and mealtime insulin for treatment of hyperglycemia and pancreatic enzyme replacement for exocrine pancreatic insufficiency.
DISCUSSION
Nearly 15 % of the United States adult population has a current diagnosis of diabetes, with type 2 DM being by far the most prevalent. 2 In clinical practice we often misdiagnose adult onset of hyperglycemia as type 2 DM, but current evidence suggests that a considerable number of those patients are indeed misdiagnosed and should be classified as either type 1 DM or type 3c. 3-7
It is important to understand the pathophysiology of different types of DM. Type 1 refers to deficiency or complete absence of insulin due to islet cell defects, while type 2 is due to decreased levels of insulin or decreased sensitivity to insulin resulting in functional deficit. Testing for C-peptide and antibodies against GAD65, IA2, insulin, and ZnT8 can aid in distinguishing between type 1 and type 2 DM. Type 3c, or pancreatogenic DM, refers to diabetes secondary to disease of the exocrine pancreas. 4 It usually occurs in patients with chronic conditions affecting the pancreas such as cystic fibrosis, hemochromatosis, or chronic pancreatitis. One proposed diagnostic criteria for type 3c DM requires the following: a diagnosis of DM, evidence of exocrine pancreatic insufficiency, abnormal pancreatic im-
20 • www. wvsma. org