PSUN262 A Case of Hypoglycemia and Diabetic Ketoacidosis in an Adult with Down Syndrome

Abstract

Abstract Introduction Down syndrome is associated with a higher risk of autoimmune endocrinopathies including diabetes mellitus. Due to intellectual disabilities characteristic of Down syndrome, good glycemic control of insulin-dependent diabetes can be challenging with several reports of complications in the literature. We present an adult female with several admissions for hypoglycemia and DKA. Case Presentation A 52-year-old female with a notable past medical history of insulin-dependent diabetes mellitus, hypothyroidism, and Down syndrome with intellectual disability equivalent to a 12-year-old presented to the emergency department unresponsive with a point of care blood glucose of 21 mg/dL. Dextrose 10% was given by EMS en route to the ER with improvement in the blood sugars to 118 on arrival. Her hemoglobin A1c was 7.1%. Of note the patient was taking insulin detemir 24 units in the morning and 30 units in the evening and metformin 1g BID. She was not checking her blood sugars before self-injecting and was skipping meals while injecting insulin. Caregiver fatigue was also reported. She was admitted one month ago for similar hypoglycemia. She was taken off insulin and continued her metformin. Her blood glucose was at inpatient goals by discharge. One month later, the patient presented with altered mentation and a point of care blood glucose greater than 600 mg/dL. Her glucose on chemistry panel was 732 mg/dL, anion gap was 21 mEq/L, bicarbonate was 21 mmol/L, and her beta-hydroxybutyrate was 1.67 mmol/L. Calculated serum osmolality was 316 mOsm/kg. The patient was admitted for DKA with a possible component of hyperosmolar hyperglycemic nonketotic coma. She was placed on a DKA protocol with an insulin drip and isotonic fluids then switched to subcutaneous insulin once her anion gap closed. She was then placed on 20 units insulin detemir daily and discharged. The patient then presented 2 weeks later with 2 days of no oral intake complicated by septic shock of unclear origin. After discussion with the mother, the patient was transitioned to comfort care and died 4 days later. Conclusion Our case illustrates the difficulty of glycemic control in patients with Down syndrome and diabetes complicated by caregiver fatigue, intellectual disability, and a complex insulin regimen. Clinicians should aim for a balance between glycemic control and treatment regimen simplicity while avoiding hypoglycemia and ketoacidosis. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.