DIABETIC KETOACIDOSIS: A RARE CAUSE OF UNUSUALLY HIGH TROPONIN I LEVEL

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Troponin elevation is typically seen in acute coronary syndrome (ACS), but it can be seen in patients with non-cardiac conditions like diabetic ketoacidosis (DKA). We present an interesting case of DKA with more than thousand fold increase in troponin I in the absence of ACS. CASE PRESENTATION: A 65-year-old female presented to emergency room with non-bloody vomiting and diarrhea for one day and confusion which started two hours before presentation. She reportedly had an insulin pump malfunction and had multiple readings of high blood glucose values at home. Medical history included type 1 diabetes mellitus (A1c-8.4%, N: 40.0 (N:0.0-0.05 ng/ml) and CK-MB of 80.9 (n=1.0-3.6 ng/ml). There was a concern for ACS. Echocardiogram showed worsening diastolic heart failure. Patient underwent left heart catheterization which revealed normal coronary arteries and elevated left and right sided pressures. With treatment and resolution of the DKA, her troponin levels gradually decreased, and patient improved significantly. She was discharged to in-patient rehabilitation facility for therapy. Insulin pump was re-calibrated before discharge. DISCUSSION: Diabetes is a major risk factor for obstructive CAD. In DKA, insulin deficiency and high concentration of counter-regulatory hormones alter myocardial cell metabolism leading to necrosis, stunning and elevated troponin, even in the absence of CAD. CONCLUSIONS: Nonspecific myocardial injury may occur in severe DKA and such patients are at an increased risk of major adverse cardiac events and mortality. The presence of bio-marker elevation does not necessarily signify ACS and metabolic abnormalities should be corrected before evaluating for the CAD. Reference #1: Manikkan, A.T., Elevated Troponin I Levels in Diabetic Ketoacidosis Without Obstructive Coronary Artery Disease. J Endocr Soc, 2018. 2(9): p. 1020-1023 Reference #2: Abdo, A.S. and S.A. Geraci, Significance of elevated cardiac troponin I in patients with diabetic ketoacidosis. J Miss State Med Assoc, 2013. 54(5): p. 127-30. Reference #3: Al-Mallah, M., et al., Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events. Clin Cardiol, 2008. 31(2): p. 67-71. DISCLOSURES: No relevant relationships by Shujaa Faryad, source=Web Response No relevant relationships by Pallavi Pradeep, source=Web Response No relevant relationships by Usama Talib, source=Web Response