aging, and absence of type 1 DM associated autoimmune markers. 5 The most common cause of type 3c DM is chronic pancreatitis( CP), occurring in 25-80 % of cases. 4, 5 However, it has also been shown to develop in up to 60 % of patients after an episode of acute pancreatitis( AP) with necrosis further raising the risk of type 3c DM. 5, 8 Damage to the pancreas affects the levels of insulin, glucagon, and incretin as well as other digestive hormones that result in exocrine pancreatic insufficiency. 4 Therefore, type 3c DM can present with both hypoglycemic and hyperglycemic states, making treatment more difficult and increasing the rate of complications. 9, 10, 11 Moreover, since glucagon is an important regulator of ketone production, it is quite rare to have DKA with type 3c DM. This case report adds to only a few published articles describing type 3c DM presenting with DKA in the setting of chronic pancreatitis. 6, 10, 12 To our knowledge, this is the first reported case of type 3c DM presenting in DKA following acute necrotizing pancreatitis.
This case highlights the importance of developing standardized guidelines for management of stress induced hyperglycemia in hospitalized patients as well as close outpatient follow up that includes hyperglycemia surveillance. One source suggested testing hemoglobin A1c and oral glucose tolerance three months after hospital discharge. 13 Given that this patient developed DKA only few days after hospital discharge it would have been more reasonable to consider offering her diabetic education and supplies prior to discharge. Insulin therapy should have been a consideration as well with close primary care follow up. 14
At present, there is little data available on the prevalence of type 3c DM; however, a recent review of available studies estimated that type 3c DM accounts for approximately 5-10 % of Western diabetic populations. 6 There are no currently published evidence-based treatment
FIGURE 1
CT scan demonstrating late phase pancreatitis, including necrosis in the pancreatic head, body, and tail with developing areas of walled off necrosis.
guidelines for type 3c DM. 11 Treatment focuses on correcting endocrine and exocrine pancreatic insufficiency, often with insulin and pancreatic enzyme replacement. 5 It is accepted clinical practice to use C-peptide values to help distinguish between type 1 DM and type 2 DM. While there is no current literature investigating this, C-peptide trending could play a role in estimating function of islet cells in patients with type 3c DM. 12 There is no published literature on recovery rates in patients with type 3c DM at this time.
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West Virginia Medical Journal • September 2025 • 21