Presentation Of Diabetic Ketoacidosis Research Articles

Clinical Presentation and Outcomes of Diabetic Ketoacidosis in Pregnancy.

To examine the presentation, management, and outcomes of pregnancies complicated by diabetic ketoacidosis (DKA) in a contemporary obstetric population. This is a case series of all admissions for DKA during pregnancy at a single Midwestern academic medical center over a 10-year period. Diabetic ketoacidosis was defined per the following diagnostic criteria: anion gap more than 12 mEq/L, pH less than 7.30 or bicarbonate less than 15 mEq/L, and elevated serum or urine ketones. Demographic information, clinical characteristics, and maternal and neonatal outcomes were assessed. Patient characteristics and clinical outcomes were compared between individuals with type 1 and those with type 2 diabetes mellitus. Between 2012 and 2021, there were 129 admissions for DKA in 103 pregnancies in 97 individuals. Most individuals (n=75, 77.3%) admitted for DKA during pregnancy had type 1 diabetes. The majority of admissions occurred in the third trimester (median gestational age 29 3/7 weeks). The most common precipitating factors were vomiting or gastrointestinal illness (38.0%), infection (25.6%), and insulin nonadherence (20.9%). Median glucose on admission was 252 mg/dL (interquartile range 181-343 mg/dL), and 21 patients (17.6%) were admitted with euglycemic DKA. Fifteen admissions (11.6%) were to the intensive care unit. Pregnancy loss was diagnosed during admission in six individuals (6.3%, 95% CI, 2.3-13.7%). Among pregnant individuals with at least one admission for DKA, the median gestational age at delivery was 34 6/7 weeks (interquartile range 33 2/7-36 3/7 weeks). Most neonates (85.7%, 95% CI, 76.8-92.2%) were admitted to the neonatal intensive care unit and required treatment for hypoglycemia. The cesarean delivery rate was 71.9%. Despite similar hemoglobin A1C values before pregnancy and at admission, individuals with type 1 diabetes had higher serum glucose (median [interquartile range], 256 mg/dL [181-353 mg/dL] vs 216 mg/dL [136-258 mg/dL], P=.04) and higher serum ketones (3.78 mg/dL [2.13-5.50 mg/dL] vs 2.56 mg/dL [0.81-4.69 mg/dL] mg/dL, P=.03) on admission compared with those with type 2 diabetes. Individuals with type 2 diabetes required intravenous insulin therapy for a longer duration (55 hours [29.5-91.5 hours] vs 27 hours [19-38 hours], P=.004) and were hospitalized longer (5 days [4-9 days] vs 4 days [3-6 days], P=.004). Diabetic ketoacidosis occurred predominantly in pregnancies affected by type 1 diabetes. Individuals with type 1 diabetes presented with greater DKA severity but achieved clinical resolution more rapidly than those with type 2 diabetes. These results may provide a starting point for the development of interventions to decrease maternal and neonatal morbidity related to DKA in the modern obstetric population.

Simultaneous presentation of thyrotoxicosis and diabetic ketoacidosis in two previously healthy men

Simultaneous presentation of thyrotoxicosis and diabetic ketoacidosis in two previously healthy men

A Case of Type 1 Diabetes Mellitus with Diabetic Ketoacidosis Presenting with Transient Severe Fatty Liver and Subsequent Liver Dysfunction.

Patients often present with severe fatty liver (FL) due to insulin deficiency at the onset of diabetic ketoacidosis (DKA). On the other hand, glycogenic hepatopathy (GH) is a possible cause of liver dysfunction in patients with DKA. We herein report a case of type 1 diabetes mellitus with severe FL at the onset of DKA, who demonstrated subsequent marked liver dysfunction after achieving an improvement of FL. As liver dysfunction persisted even after the FL improved, GH was suspected to be the cause of liver dysfunction. FL and GH have different prognoses and should therefore be differentiated using imaging studies and biopsies.

The Prevention of Diabetic Ketoacidosis in Patients with Type 2 Diabetes on Sodium-Glucose Transport Protein 2 Inhibitors

Background: Sodium-Glucose Transport Protein 2 Inhibitors (SGLT2Is) effectively control diabetes. Diabetic ketoacidosis (DKA) has been reported as a life-threatening adverse effect due to SGLT2Is use. Aim: This study aims to review the current evidence of incidence, predisposing factors and the prevention of DKA in T2DM patients on SGLT2Is use. Methods and Materials: Two reviewers have conducted a search strategy of studies published in English between August 2012 and November 2020, in EBSCOhost, Google Scholar, PubMed, Science Direct and Wiley. Two reviewers independently assessed the eligibility and quality of the studies and extracted the data. Results: 85 studies were identified in the initial search; 75 records were removed and finally, 10 studies were included. Only studies discussing the prevention of DKA in T2DM patients on SGLT2Is were selected, extracted and categorized into main domains that included SGLT2Is use inT2DM patients and DKA (50%), SGLT2Is use in T2DM patients (20%), the clinical presentation of DKA (20%) and DKA prevention (10%). Six studies showed SGLT2Is increased the risk of DKA with very low rates in two studies. The precipitating factors of DKA in all included studies were revealed asstopping or reducing insulin, trauma, infection, surgery, severe acute illness, vigorous exercise, dehydration, low carbohydrate intake and excessive alcohol intake. In two studies DKA can be prevented by wakefulness and education, in one study by closed follow-up, in one study by regular monitoring and adjustment of medications and in two studies by recognition of patients at risk. Conclusions: This review summarized the prevention of DKA in T2DM patients on SGLT2Is use with consideration of incidence, a summary of evidence and predisposing factors. Physicians, health care providers and patients should be aware of SGLT2Is use, regular follow up, precipitating factors, symptoms, signs and prevention of DKA. Keywords: Sodium-Glucose Transport Protein 2 Inhibitors SGLT2Is, Type 2 diabetes mellitus, Diabetic Ketoacidosis, Scoping Review.

Challenges in Pediatric Diabetes Classification: A Case Report

Challenges in Pediatric Diabetes Classification: A Case Report

SAT438 Nivolumab Induced Endocrinopathies- Outcomes And Learning

Abstract Disclosure: K. Kethireddi: None. S. Jhetam: None. S.B. Parthasarathy: None. Background: Nivolumab is an anti PD-1 mAB (Programmed Cell Death protein) used in the treatment of melanoma, renal, head & neck and other cancers. Use of Nivolumab either as a single therapy or in combination with other immune check point inhibitors (CPI) like Ipilimumab, Pembrolizumab often results in immune mediated endocrinopathies. Existing literature on Nivolumab indicates median time to the onset of hyperthyroidism, hypothyroidism, type 1 diabetes mellitus, and hypophysitis as 1.5 months, 2.9 months, 4.4 months and 4.9 months respectively. Our objective is to add to the existing body of knowledge, compare local data on presentation and other variables of these endocrinopathies with recommendations to improve diagnosis and access to treatment of these endocrinopathies. Design: It is a retrospective analysis of the patients who received Nivolumab (single or combination therapy) between 2019 and 2022 in our hospital. Methodology: A total of 83 patients were treated either with single therapy Nivolumab (n=44) or combination therapy (n=39) and were screened for immune endocrine toxicities. Data was collected mainly from hospital based clinical software for routine use. Data was also collected on prior endocrine tests such as Hba1c and Thyroid function, if done prior to commencement of immunotherapy. Major results: Nineteen patients (23%) developed immune related endocrinopathies which included Thyroiditis/hypothyroidism (n= 12) followed by adrenalitis (n= 6), Type 1 Diabetes (n=1) and hypophysitis (n=3). Onset of thyroid dysfunction occurred between 4 to 8 weeks, adrenalitis between 8 to 32 weeks, hypophysitis between 4 weeks to 12 weeks and 24 weeks for type 1 diabetes mellitus. All patients were appropriately counselled and were provided with Patient Information leaflet. Regular screening bloods (Hba1c, Glucose, Cortisol and Thyroid function tests) were requested in most patients. Emergency presentations of Diabetic ketoacidosis (n=1) and Adrenal insufficiency (n=2) were noted with no mortality. Conclusion: 23% of the patients on Nivolumab had immune mediated endocrinopathy with Thyroiditis/Hypothyroidism being the commonest and the earliest endocrine abnormality. A Standard Operating Procedure for acute endocrine emergencies post Immunotherapy based on Society for Endocrinology guidance, needs to be implemented with education to create greater awareness given the expected high prevalence of these endocrinopathies post Immune CPI therapies. We recommend oral steroid (prednisolone/hydrocortisone) rescue pack and patient education on SMBG (Self-monitoring of blood glucose) as a part of sick day rule management in these patients and we believe this to be lifesaving and resource saving measure given the critical nature of these endocrine emergencies post immune CPI therapies. Presentation: Saturday, June 17, 2023

Emergency Department Presentations of Diabetic Ketoacidosis in a Large Cohort of Children

Background. Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of childhood diabetes. However, the influence of demographic factors on presentation are not well-defined. Methods. We included children from 12 centers who were <18 years with DKA (glucose > 300 mg/dL, serum pH < 7.25, or serum bicarbonate <15 mEq/L) enrolled in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) Trial. Data were also collected for children who presented to the centers during the enrollment period but were not enrolled due to disease or treatment-related reasons. We compared demographic, clinical, and biochemical findings among children with newly and previously diagnosed diabetes and children in different age groups. Results. Of the 1,679 DKA episodes in 1,553 children, 799 (47.5%) episodes occurred in children with newly diagnosed diabetes and 396 (23.6%) were severe (pH < 7.1). Newly diagnosed children <6 years of age were not more likely to have severe DKA in terms of pH, but had more severe hypocarbia and higher blood urea nitrogen levels, factors previously associated with the risk of cerebral injury. Lower socioeconomic status (SES) (based on family income and maternal education level) were associated with more severe DKA in new onset children, and recurrent DKA in the previously diagnosed children. Conclusions. Greater efforts are needed to identify the children with diabetes early and to prevent recurrent DKA, particularly among children in low-SES groups. Young children with DKA may need more intensive monitoring due to higher risk of cerebral injury.

Balanced crystalloids (RInger’s lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial

BackgroundCurrent guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer’s Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA.MethodsWe describe a protocol for BRISK-ED (Balanced crystalloids [RInger’s lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada.Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS.The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann–Whitney U, or chi-square tests will be used to compare groups as appropriate.DiscussionThe results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes.Trial registrationClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.

Diagnosing and treating diabetic ketoacidosis in dogs and cats

Background: Patients in diabetic ketoacidosis (DKA), which is a complication of diabetes mellitus, will often present with a multitude of electrolyte and fluid balance abnormalities which require immediate treatment. Although historically considered to be associated with a poor prognosis, if sufficient owner finances are available then most patients can be successfully treated with an approach tailored to the individual patient, owner and practice.Aim of the article: This article outlines the aetiology and clinical presentation of DKA in cats and dogs and discusses the treatment options available when presented with these patients.

Clinical profile and outcome of children presenting with diabetic ketoacidosis at a tertiary care hospital in Dakshina Kannada

Background: Diabetic ketoacidosis (DKA) is the most serious metabolic disturbance of type 1 diabetes mellitus (T1DM) and about 25 to 40% of the newly diagnosed T1DM children present with DKA. This research was conducted to study the clinical profile and identify the precipitating factors at time of presentation of DKA and to correlate the type onset of disease with the severity of DKA and the treatment outcome. Methods: Ambispective record based study of children admitted in in the paediatric ward of a tertiary care hospital with DKA between 01 July 2019 and 31 January 2022. Results: A total of 19 patients were enrolled and the mean age of presentation was 10.79±4.17 years with a female predominance. The family history of type 2 DM was noted in 73.7% and osmotic symptoms in 68.4% of the patients. 52.6% of the patients presented in severe DKA. Mean HbA1C noted was 15.14±2.74%. Acute Kidney Injury was present in 10.5% of the patients. Pneumonia was the major precipitating factor. The average length of hospital stay was 7.42±3.27 days. There was no significant correlation with the type of onset of T1DM and the treatment outcome. There was a significant reduction in HbA1c (p<0.05) on follow-up. Conclusions: This study highlights the need for creating awareness, early referral and timely management of T1DM presenting not only in DKA but also during the ambulatory management.

Relationships among biochemical measures in children with diabetic ketoacidosis.

Investigating empirical relationships among laboratory measures in children with diabetic ketoacidosis (DKA) can provide insights into physiological alterations occurring during DKA. We determined whether alterations in laboratory measures during DKA conform to theoretical predictions. We used Pearson correlation statistics and linear regression to investigate correlations between blood glucose, electrolytes, pH and PCO2 at emergency department presentation in 1,681 pediatric DKA episodes. Among children with repeat DKA episodes, we also assessed correlations between laboratory measures at the first vs. second episode. pH and bicarbonate levels were strongly correlated (r=0.64), however, pH and PCO2 were only loosely correlated (r=0.17). Glucose levels were correlated with indicators of dehydration and kidney function (blood urea nitrogen (BUN), r=0.44; creatinine, r=0.42; glucose-corrected sodium, r=0.32). Among children with repeat DKA episodes, PCO2 levels tended to be similar at the first vs. second episode (r=0.34), although pH levels were only loosely correlated (r=0.19). Elevated glucose levels at DKA presentation largely reflect alterations in glomerular filtration rate. pH and PCO2 are weakly correlated suggesting that respiratory responses to acidosis vary among individuals and may be influenced by pulmonary and central nervous system effects of DKA.

Variation of Newly Diagnosed Type 1 Diabetes Mellitus Cases During Covid-19 Pandemic: A Review

Background Type 1 diabetes mellitus (T1DM) is one of the chronic diseases that timely and correct management affects the outcome of these patients. COVID-19 is an acute respiratory infection that has created a disproportionate situation for individuals and healthcare systems. The resulting pandemic is associated with delayed presentation of patients as well as increased frequency and severity of acute complications. Objectives This review study aims to investigate the incidence, initial presentation, frequency, and severity of diabetic ketoacidosis (DKA) as well as changes in demographic findings, such as age and sex in newly diagnosed T1DM children and adolescents during the COVID-19 pandemic. Methods The search was conducted in different databases, using the keywords: T1DM, COVID-19, pediatrics, and incidence to find the related articles published in English from December 31, 2019, to March 3, 2022. Results There is no clear evidence for increase in the incidence of T1DM and the frequency and severity of DKA in female and younger people during the pandemic compared to the pre-pandemic period. Further studies with larger sample sizes are needed to better understand the role of pandemic on disease incidence and acute complications. Conclusions: To reduce the incidence of DKA and speed up the diagnosis of T1DM during the pandemic, people should be informed about their symptoms.

Epidemiological trends in the presentation of diabetic ketoacidosis in children newly diagnosed with type 1 diabetes from 2011 to 2017 in Kuwait.

Monitoring the trends in the presentation of T1D over decades cannot be underestimated as it provides a rich source of information on diabetes-related complications like DKA. DKA represents a medical emergency, with potentially fatal outcome, and thus the prevention of DKA is a priority in diabetes care. The aim of this study is to report on trends in the presentation of DKA in children newly diagnosed with T1D in Kuwait. This study is based on a retrospective review of children newly diagnosed with T1D aged 14 years or less at three Governmental Hospitals representing three health sectors out of the total six health sectors in the country during the period 2011-2017. A total of 799 children (376 males and 423 females) were newly diagnosed with T1D. 287 children presented with DKA (35.9%) with only 73 children (9.1%) classified as severe. During the years 2011 to 2017, we note that the percentage of children older than 6 years of age presenting with severe DKA has decreased significantly (p=0.022). Unfortunately, this has not been replicated in children younger than 6 years. This study highlights the importance of continued monitoring of clinical characteristics of children at diagnosis of T1D specifically presenting with DKA to enable diabetes care professionals to appreciate the multifaceted aspects of T1D, in particular the importance of raising awareness of the early signs of the onset of T1D with special attention to DKA and its severe consequences.

Severity and Resolution of Diabetic Ketoacidosis in Newly Diagnosed Type 1 Diabetic Children before and During The COVID-19 Pandemic

OBJECTIVES: To epidemiologically assess the influence of COVID-19 pandemic on newly diagnosed type 1 diabetes mellitus presenting with diabetic ketoacidosis at the teaching hospital of the university, Eastern province, Saudi Arabia. METHODS: We enrolled newly diagnosed type 1 diabetes mellitus cases among pediatric patients attending the emergency department and outpatient clinics during 2019-2021. The participants' data were collected from electronic medical records which included patients' age at diagnosis, sex, nationality, height, weight, year of diagnosis, length of stay, presentation, random blood sugar, blood gas readings, electrolyte panel, and time of resolution of the diabetic ketoacidosis if present. RESULTS: 108 patients were included with an average age of 8.87 ± 4.21 years and 53.70% were females. The demographic characteristics of all diabetic pediatric patients prior to COVID-19 and during COVID-19 were studied and the difference was statistically insignificant. Furthermore, initial pH and HCO3 tests were found to be lower in the moderate to severe diabetic ketoacidosis group (7.17 and 11.2, respectively) compared to the mild group (7.27 and 15.50, respectively) and the differences were statically significant (P < 0.001). CONCLUSION: Patients newly diagnosed with type 1 diabetes mellitus during the COVID-19 pandemic tended to have a more severe presentation of diabetic ketoacidosis in terms of PH and HCO3.

LBSUN292 Learning Lesson From A Case of Fulminant Type 1 Diabetes Mellitus Shortly After Pembrolizumab Treatment

Abstract Background Immune checkpoint inhibitors (ICIs) in cancer treatment are considered one of the major breakthroughs in the past decade. Pembrolizumab (PBL) is one of the immune checkpoint inhibitors that targets the programmed cell death protein-1 (PD-1) receptor in order to block its interaction with programmed cell death ligand-1 (PD-L1) and programmed cell death ligand-2 (PD-L2). By inhibition of these molecules, PBL helps increase T-cell activation against cancer cells. Unfortunately, this inhibition also enhances autoimmunity against normal cells, leading to immune-related adverse events (irAEs) including endocrinopathies. Unlike other irAEs, endocrinopathies are usually irreversible upon diagnosis. While hypophysitis, hypo/hyperthyroidism, and adrenal insufficiency are more commonly reported, type 1 diabetes mellitus (T1DM) is also seen around 0.9 to 1.9% of cases. Unfortunately, it can become fatal if not being promptly recognized. To raise awareness about this life-threatening adverse event, we are reporting a case of new onset T1DM, presenting with diabetic ketoacidosis (DKA) only after 22 days of the first PBL infusion. Clinical case A 19-year-old male was recently diagnosed with NUT (nuclear protein in testis) carcinoma of the left floor of mouth with high PD-L1 score. NUT carcinoma is a rare type of squamous cell cancer with chromosomal rearrangement in the nuclear protein in testis gene (NUTM1) that makes the cancer aggressive and resistant to standard therapy, hence requiring a multimodal approach. This patient underwent surgery followed by concurrent cisplatin-radiation and PBL. Two weeks after his first PBL infusion, he suddenly developed polydipsia, polyuria, and nausea. He continued to receive the second PBL dose on day 20 and developed DKA on day 21. His work-up revealed a plasma glucose of 856 mg/dL, anion gap of 20 (H), CO2 of 17 mEq/L (L), and beta-hydroxybutyrate of 3.35 mmol/L (H), while hemoglobin A1C of only 5.5% suggesting his fulminant progression. He was immediately treated with DKA protocol with clinical improvement. The patient was discharged on basal bolus insulin regimen. He had non-detectable C-peptide (<0.10 ng/mL) and high GAD Antibody (>250 IU/mL) levels, which was consistent with PBL induced T1DM. Conclusion PBL use has been linked to multiple endocrinopathies and even though rare, DKA can also be seen in setting of T-cell mediated irreversible damage to pancreas beta cells. Due to life threatening potential of DKA, clinicians should monitor patients receiving immune checkpoint inhibitors closely and should be aware symptoms of hyperglycemia for earlier intervention. | Keywords: pembrolizumab, NUT carcinoma, diabetic ketoacidosis Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Acute presentation of immunotherapy-related diabetes mellitus without ketoacidosis, low C-peptide or elevated HbA1c.

The rapid rise in the use of immune checkpoint inhibitors as systemic cancer therapy has seen the emergence of immunotherapy-induced diabetes, a severe irreversible immunotherapy-related adverse event. Affected patients typically present with diabetic ketoacidosis (DKA) and low C-peptide consistent with insulin deficiency secondary to autoimmune β-cell destruction. We present the unusual case of a 61-year-old female with metastatic ampullary duodenal adenocarcinoma with primary tumour adjacent to the pancreatic head. She was commenced on immunotherapy after conventional systemic chemotherapy. Acute-onset hyperglycaemia was detected after 7 weeks on weekly blood glucose monitoring, with no glucocorticoid use or prior history of diabetes. On presentation, there was no evidence of DKA, and her glycated haemoglobin level was within the normal non-diabetic range at 5.3%, reflecting the acuity of her presentation. Initial serum C-peptide was preserved; however, it became undetectable a few weeks later, confirming insulin deficiency. We describe a case of atypical presentation of immunotherapy-induced diabetes, review the existing literature on this emerging clinical entity and discuss the differential diagnosis for new-onset diabetes mellitus in patients with metastatic cancer. Regular proactive glycaemic monitoring in patients receiving immunotherapy, particularly antibodies against programmed death ligand 1 and PD1, can facilitate very early detection of immunotherapy-induced diabetes, prompting insulin commencement and avoiding life-threatening presentations of diabetic ketoacidosis. Glycated haemoglobin can be within the normal range in patients diagnosed acutely with immunotherapy-induced diabetes. Serum C-peptide can be preserved initially in patients diagnosed with immunotherapy-induced diabetes but is likely to become undetectable during their illness. New-onset diabetes in patients with metastatic cancer carries a broad differential diagnosis.

ODP273 Schmidt Syndrome Causing Multiorgan Failure

Abstract Introduction To our knowledge there has not been a case report published on the acute presentation of Schmidt syndrome (Polyglandular Autoimmune Syndrome Type 2) in which all three manifestations of type 1 diabetes mellitus (T1DM), primary adrenal insufficiency, and hypothyroidism were found and diagnosed at the same time. Case Description A 32-year-old male with suspected alcohol abuse presented to the hospital with nausea, vomiting, and weakness of two weeks duration after sustaining a fall. He was admitted for Diabetic Ketoacidosis (DKA) and shock requiring three pressors with unclear etiology. Labs were significant for severe hyponatremia of 113 mmol/L (136-145), elevated anion gap of 22, glucose 206 mg/dL (70-100), bicarbonate 11mmol/L (21-31), beta hydroxybutyrate 5.90 mmol/L (0. 0-0.42), and pH 7.22 (7.35-7.45) with Hemoglobin A1c 14.5% (<5.7). An insulin drip was instituted for DKA and the hyponatremia persisted. Cortisol was found to be suppressed at 3. 0 ug/dL (3.1-22.4) with significantly elevated ACTH 220.4 pg/mL (7.2-63.3) suggesting a new diagnosis of primary adrenal insufficiency. IV hydrocortisone 100 mg q8H was started on day 2 of hospitalization. Thyroid labs showed elevated TSH 10.10 uIU/mL (0.36-3.74) confirming hypothyroidism, prompting initiation of IV levothyroxine. His hospital course was complicated by cardiac arrest and acute respiratory failure requiring intubation. Cardiac work up was negative except for severe non-ischemic cardiomyopathy with significantly reduced ejection fraction of 20-25%. Bronchoscopy was performed and showed no evidence of obstructing pulmonary etiologies. SARS Coronavirus PCR was negative. He also had shock liver along with Disseminated intravascular coagulation (DIC). His kidney function worsened requiring continuous kidney replacement therapy (CRRT). Urine microscopy showed granular casts consistent with acute tubular necrosis. TPO antibodies, adrenal antibodies, GAD antibodies, and Zinc Transporter 8 antibodies all came back positive along with an undetectable C- peptide confirming the diagnosis of Hashimotos hypothyroidism, primary adrenal insufficiency, and T1DM respectively. He was eventually discharged on basal bolus insulin regimen, levothyroxine 75 mcg po daily, fludrocortisone 0. 05 mg po daily, and prednisone 5 mg po daily. The patient had multifactorial shock from an acute presentation of DKA, primary adrenal insufficiency, and hypothyroidism all presenting simultaneously. Conclusion This case illustrates the severe impact of having three endocrine organs affected all at once. The prevalence of Schmidt syndrome is very low at 1: 20,000 in the general population and can be associated with other non-endocrine autoimmune disorders. Prevalence of autoimmune thyroid disease is 70%, T1DM 50%, and Addison's disease is almost 100%. Due to the low prevalence, one needs a high clinical suspicion with the correct lab findings to diagnose this disease. Incorrect diagnoses or a late diagnosis can lead to life threatening consequences to the patient. The mainstay of treatment is hormone replacement, with corticosteroids given before thyroid replacement. Presentation: No date and time listed

SUDDEN LOSS OF VISION: A RARE PRESENTATION OF DIABETIC KETOACIDOSIS IN THE ICU

SUDDEN LOSS OF VISION: A RARE PRESENTATION OF DIABETIC KETOACIDOSIS IN THE ICU

Presentation of Severe Diabetic Ketoacidosis in New-Onset Type One Diabetes Mellitus: The Importance of a Broad Differential in an Otherwise Healthy Population in the Operational Environment.

Diabetic ketoacidosis (DKA) is a serious disease entity that must be diagnosed quickly for urgent management in the intensive care unit. Keeping DKA in the differential diagnosis is important, especially in a forward deployed, resource-poor setting. The symptoms and signs of DKA are nonspecific, including fatigue, polydipsia, polyuria, weakness, weight loss, nausea, vomiting, and abdominal pain with tachycardia and tachypnea on exam. The testing capability to evaluate for DKA includes a glucometer, urine dipstick, and basal metabolic panel, all of which can be done in most forward deployed settings. The need for a high index of suspicion for DKA in patients with these symptoms is required due to the lack of life-saving insulin and intensive lab monitoring required. The downstream effects of DKA include diabetic coma and death. We present a case report of a 21-year-old otherwise healthy, active duty, male Marine who presents to the clinic with a chief complaint of 4days of headache and 1day of nausea with four episodes of non-bloody, non-bilious emesis along with epigastric abdominal pain. He returned to the clinic 2days later with evidence of tachycardia and increased work of breathing, at which time there was a concern for a pulmonary embolus. By the time he was transferred to the emergency room, he was in severe DKA. The patient was treated in the intensive care unit and made a full recovery. He was processed for limited duty and medical board upon hospital discharge.

Diabetic Ketoacidosis in Pregnancy: An Overview of Pathophysiology, Management, and Pregnancy Outcomes

Diabetic ketoacidosis (DKA) is an obstetrical emergency that is associated with an elevated risk of adverse pregnancy outcomes. This includes pregnancy loss in up to 1 in 3 cases. Due to the normal metabolic changes that occur during pregnancy, females who are pregnant are more vulnerable to DKA, and it can occur at lesser than expected degrees of hyperglycaemia. Presenting symptoms can be non-specific and include nausea and vomiting, fatigue, polydipsia, and polyuria. DKA may be the first presentation of previously undiagnosed diabetes. Therefore, high index of suspicion, along with prompt diagnosis and management, is essential. The cornerstones of management include intravenous insulin, intravenous fluids, and electrolyte replacement. Treatment generally follows the principles for DKA management outside of pregnancy, with some additional considerations. Close maternal and fetal monitoring is essential, and intensive care unit admission is typically required to adequately achieve this goal. In all situations, a thorough investigation should occur to address the underlying cause of the DKA and prevent further episodes. This review article outlines the potential etiopathogenesis, clinical presentation, and management of DKA in pregnancy.