High Anion Gap Research Articles

Managing Metabolic Acidosis in Chronic Renal Diseases

One of the most common side effects of chronic kidney disease is metabolic acidosis (CKD). It is associated with the development of CKD and various other functional disorders. Metabolic acidosis can be a common complication associated with progressive loss of kidney function. The form can be a metabolic acidosis with a non-anion gap or metabolic acidosis with a high or mixed anion gap. Reduced kidney ability to maintain acid-base homeostasis results in acid accumulation, causing various complications such as decreased nutritional status such as wasting muscle-hypoalbuminemia, inflammation, uremic bone disease and its association with increased mortality. In addition to the side effects associated with acid retention, metabolic acidosis can also cause kidney damage, possibly through stimulation of adaptive mechanisms aimed at maintaining acid-base homeostasis in the event of decreased renal function. chronic kidney disease (CKD), and therefore offers an effective, safe and affordable reno-protective strategy. This paper will discuss the physiology and pathophysiology of acid-base homeostasis in CKD, namely the mechanism of metabolic acidosis capable of impairing kidney function, and its relation to the benefits of alkaline therapy. based on clinical trials

Neuroimaging in Acute Ethylene Glycol Toxicity (P8-4.006)

<h3>Objective:</h3> To describe unique neuroradiological features of Ethylene Glycol poisoning. <h3>Background:</h3> Ethylene Glycol (EG) is a sweet tasting, industrial compound that is ubiquitously found in various consumer products (antifreeze, paints, solvents, and cosmetics). Ingestion of EG results in toxicity with characteristic metabolic, pathological, and imaging findings. Toxicity classically presents with a severe anion gap metabolic acidosis, an osmolar gap, and multi-organ involvement. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 64-year-old man presented with acute onset nausea, recurrent vomiting, and ataxic gait. Within a few hours, he became progressively confused, lethargic, and eventually obtunded requiring intubation for airway protection. On physical examination, he was unresponsive but had preserved brainstem reflexes. Laboratory tests showed elevated high anion gap metabolic acidosis (HAGMA) with pH of 7.23, bicarbonate of 13 mmol/L, anion gap of 38 mmol/L, and lactic acid of 2.2 mmol/L. Ethanol, salicylates, acetaminophen, and ketones were undetectable. Further tests revealed methemoglobin level of 1%, increased serum osmolality 328 mOsm/kg, and osmolal gap 71 mOsm/kg. CT head was unrevealing. Due to the HAGMA with hyperosmolality suggesting a toxic alcohol ingestion, the patient was empirically treated with fomepizole 15 mg/kg. EEG showed severe diffuse cerebral dysfunction. He soon developed progressive renal failure requiring hemodialysis. MRI of the brain without contrast revealed bilateral and symmetric enlargement of the basal ganglia and thalami with T2-weighted hyperintensities, as well as T2-weighted hyperintensities involving the brainstem and scattered cortical areas. Ethylene glycol concentration from blood drawn on admission resulted at 1962 mg/dL confirming EG poisoning. <h3>Conclusions:</h3> This case highlights MRI brain findings of T2-weighted hyperintensities in deep gray matter structures in EG toxicity. Current scientific literature infrequently reports any neuroradiologic findings. Clinicians should be cognizant of these neuroradiologic features and use MRI as a supportive diagnostic tool in the proper clinical context while awaiting a definitive EG concentration. <b>Disclosure:</b> Dr. Hiana has nothing to disclose. Dr. Mulatu has nothing to disclose. Dr. Sharma has nothing to disclose. Dr. Askandaryan has nothing to disclose. Dr. Mulatu has nothing to disclose. Dr. Anziska has nothing to disclose.

The serum anion gap is associated with the prognosis of coronary artery bypass grafting (CABG): analysis based on the MIMIC-IV database.

The serum anion gap (AG) has been reported to be an important prognostic indicator for patients in intensive care units. To explore the potential relationship between the serum AG and 30-day mortality in patients who underwent CABG. All data were collected from the Medical Information Mart for Intensive Care Ⅳ (MIMIC-Ⅳ) database. We divided patients into 3 groups according to AG tertiles. The primary outcome of our study was the 30-day mortality of patients who underwent CABG. The relationship between the serum AG and mortality in individuals who underwent CABG was estimated using Cox proportional hazard models. Subgroup analysis for effect modification was conducted with a likelihood ratio test. A total of 5,102 eligible subjects were included in our analysis. After adjusting for confounding factors, every unit increase in the AG was associated with a 22% higher odds of 30-day mortality in patients who underwent CABG [hazard ratio (HR), 95% confidence interval (CI): 1.22, 1.13-1.33] When the AG was converted into a categorical variable, the high AG group had a higher risk of 30-day mortality than the low AG group in the fully adjusted model (HR, 95% CI: 3.99, 1.35-11.76). Tests for trends were statistically significant (p-value < 0.05). Subgroup analysis demonstrated that higher mortality was related to the subgroups of people ≥ 70 years and females. The serum AG was an independent predictor of short-term prognosis in patients who underwent CABG. A high AG was associated with an increased risk of 30-day mortality after CABG.

Physiological and clinical variables identify ARDS classes and therapeutic heterogeneity to glucocorticoids: a retrospective study

ObjectiveWe aimed to identify new classes in acute respiratory distress syndrome (ARDS) using physiological and clinical variables and to explore heterogeneity in the effects of glucocorticoid therapy between classes.MethodsUsing the Medical Information Mart for Intensive Care-IV database, we identified patients with ARDS. Potential profile analysis was used to identify classes with physiological and clinical data as delineating variables. Baseline characteristics and clinical outcomes were compared between classes. The effect of glucocorticoid treatment was explored by stratifying by class and glucocorticoid treatment.ResultsFrom 2008 to 2019, 1104 patients with ARDS were enrolled in the study. The 2-class potential analysis model had the best fit (P < 0.0001), with 78% of patients falling into class 1 and 22% into class 2. Additional classes did not improve the model fit. Patients in class 2 had higher anion gap, lactate, creatinine, and glucose levels and lower residual base, blood pressure, and bicarbonate compared with class 1. In-hospital mortality and 28-day mortality were significantly higher among patients in class 2 than those in class 1 (P < 0.001). Heterogeneity of glucocorticoid treatment was observed, stratified by class and treatment, with no significant effect in class 1 (P = 0.496), increased mortality in class 2 (P = 0.001), and a significant interaction (P = 0.0381). In class 2, 28-day survival was significantly lower with glucocorticoid treatment compared with no hormone treatment (P = 0.001).ConclusionWe used clinical and physiological variables to identify two classes of non-COVID-19-associated ARDS with different baseline characteristics and clinical outcomes. The response to glucocorticoid therapy varied among different classes of patients.

Low Serum Bicarbonate in a Patient With Diabetes Mellitus:: A Quiz

Low Serum Bicarbonate in a Patient With Diabetes Mellitus:: A Quiz

Association of globulin concentrations with prognosis in horses with lymphoma.

Lymphoma is the most common hemopoietic neoplasia in horses. Common clinicopathologic abnormalities in equine lymphoma include hyperglobulinemia, hypoalbuminemia, hyperfibrinogenemia, anemia, thrombocytopenia and lymphocytosis. Hypoglobulinemia has been reported in other species with lymphoma, however it has not been well-described in horses. The objectives of this study were to examine the prevalence of hypoglobulinemia in equine lymphoma, and to identify prognosis and clinicopathological abnormalities associated with serum globulin concentrations. Ninety-six horses with lymphoma were investigated in this retrospective study. Patients were allocated into groups based on serum globulin concentration. Survival analysis was performed to determine risk factors associated with globulin concentration and outcome. Nineteen horses were hypoglobulinemic (≤2.1 g/dL), 63/98 were normoglobulinemic (2.2-4.3 g/dL), and 16/98 were hyperglobulinemic (≥4.4 g/dL). Hyperglobulinemia was associated with a higher anion gap (P = 0.0005), lower bicarbonate (P = 0.006), sodium (P = 0.03) and chloride concentrations (P = 0.002), and higher total protein than hypoglobulinemic horses (P < 0.0001). For location, 37% of horses with mucocutaneous lymphoma were hypoglobulinemic, compared to none in the hyperglobulinemic group (P = 0.02). Survival times were significantly different between low, normal and high globulin groups (P = 0.0002, median [range] survival times: 333 [1-3792], 43 [1-4,001] and 4 [1-129] days, respectively). Significant risk factors for shortened time to death were hyperglobulinemia (HR 2.4, P = 0.02), T cell lymphoma (HR 3.5, P < 0.0001), and multicentric (HR 3.1, P = 0.0008) and mediastinal (HR 6.4, P = 0.006) forms of lymphoma. Lack of chemotherapy was associated with shortened survival time (HR 4.5, P < 0.0001). B cell lymphomas (P < 0.0001) and mucocutaneous lymphoma location (P < 0.0001) were associated with longer survival times. Serum globulin concentrations are associated with location of lymphoma, clinicopathologic abnormalities, and survival times in equine lymphoma.

Managing Severe Acute Asthma Exacerbation in Pregnancy during the COVID-19 Pandemic: A Case Report from a Resource-limited Setting

BACKGROUND: One-third of pregnant women will experience worsening asthma requiring emergency hospitalization. However, no report comprehensively discussed the management of asthma attacks in pregnant women in impoverished settings. We attempt to illuminate what general practitioners can do to stabilize and improve the outcome of severe acute asthma exacerbations in primary care with resource limitations. CASE REPORT: A nulliparous 29-year-old woman in her 21st week of pregnancy presented severe acute asthma exacerbation in moderate persistent asthma with uncontrolled asthma status along with gestational hypertension, uncompensated metabolic acidosis with a high anion gap, anemia, respiratory infection, and asymptomatic bacteriuria, all of which influenced her exacerbations. This patient was admitted to our resource-limited subdistrict hospital in Indonesia during the COVID-19 pandemic for optimal stabilization. Crystalloid infusions, oxygen supplementation, nebulized beta-agonist with anticholinergic agents, inhaled corticosteroids, intravenous methylprednisolone, broad-spectrum antibiotics, subcutaneous terbutaline, mucolytics, magnesium sulphate, oral antihypertensives, and continuous positive airway pressure were used to treat her life-threatening asthma. After she was stabilized, we referred the patient to a higher-level hospital with more advanced pulmonary management under the supervision of a multidisciplinary team to anticipate the worst scenario of pregnancy termination. CONCLUSION: Limitations in primary care, including the lack of sophisticated intensive care units and laboratory panels, may complicate challenges in managing severe acute asthma exacerbation during pregnancy. To enhance maternal-fetal outcomes, all multidisciplinary team members should be well-informed about key asthma management strategies during pregnancy using evidence-based guidelines regarding the drug, rationale, and safety profile.

Chromobacterium violaceum Related Urinary Tract Infection: A Case Report

Chromobacterium violaceum (C. violaceum) is a motile, gram-negative bacilli found in water and moist soil. Infections due to C. violaceum are uncommon but have a significant mortality rate (upto 80%) due to their tendency for haematogenous dissemination resulting in sepsis. The organism has been reported to cause skin and soft tissue infections, diarrhoea, bacteremia, and visceral abscess; Urinary Tract Infection (UTI) is rarely seen. Here, a 41-year-old male diabetic who presented with fever, altered sensorium and burning micturition caused by C.violaceum is presented. Initial investigations revealed an increased Random Blood Sugar (RBS) level, high anion gap metabolic acidosis with normal renal and liver function (except for hypoalbuminemia). Diabetic ketoacidosis, probable meningitis and urosepsis were considered as differential diagnosis. On culture of urine sample, C. violaceum was isolated which was susceptible to all the antibiotics tested except amikacin. Blood culture was reported as sterile. Patient was successfully treated with susceptible antibiotic (ciprofloxacin) and repeat culture of urine was also sterile. Early diagnosis and adequate treatment is necessary to reduce the risk of progression to fatal infection.

Warning about use of pesticides containing inpyrfluxam for suicide.

Warning about use of pesticides containing inpyrfluxam for suicide.

Metanol zehirlenmesi olan hastalarda mortalite ile ilişkili risk faktörleri: retrospektif bir çalışma

Aim: Methanol poisoning (MP) is an significant medical problem worldwide, and despite advances in diagnosis and treatment, the mortality rate in these cases remains high. This study aimed to evaluate the clinical and laboratory factors to determine in-hospital mortality in patients with MP.Methods: This single-center, retrospective, observational study was conducted with 65 adult MP cases visiting the emergency department (ED) of a tertiary training and research hospital, between January 01, 2017 and February 01, 2022. Data was statistically compared between survivors and non-survivors.Results: The in-hospital mortality rate was 41.5%. The rate of cases with respiratory distress, low Glasgow coma scale (GCS) (≤8), and delayed arrival to the hospital (&amp;gt;24 hours) was higher in the group of non-survivors compared to the group of survivors. Non-survivors had a higher anion gap (30.5 mEq/L vs. 25.5mEq/L), base excess (-25.0 mmol/L vs. -18.6 mmol/L), lactate (10.2 mmol/L vs. 2.2 mmol/L) levels, and lower pH (6.76 vs. 7.14) and bicarbonate (6.3 mmol/L vs. 10.3 mmol/L) levels than survivors (p&amp;lt;0.001). In ROC analysis, pH (AUC= 0.916) and base excess (AUC=0.915) were blood gas parameters with the highest AUC values in predicting mortality in MP cases. Folate use in the treatment had a statistically significant effect on mortality (P=0.015).Conclusion: In MP cases, delay in a hospital visit, severe metabolic acidosis, high lactate levels, low GCS on arrival to the ED and no folate therapy, were associated with increased in-hospital mortality rates. Our data will contribute to the clinical management of MP patients and the development of treatment protocols.

Predictive value of the serum anion gap for 28-day in-hospital all-cause mortality in sepsis patients with acute kidney injury: a retrospective analysis of the MIMIC-IV database.

The kidney is one of the most vulnerable organs in sepsis patients, which mainly manifests as sepsis-associated acute kidney injury (SA-AKI). The case fatality rate of SA-AKI is high, and thus, predicting the risk of SA-AKI-related death is hugely significant. Anion gap (AG) is an important indicator in critical illness patients. The present study aimed to analyze the predictive value of the AG for the short-term prognosis of SA-AKI patients. SA-AKI patient data from the Medical Information Mart for Intensive Care (MIMIC-IV) database were collected retrospectively. Hospitalized septic patients who meet the inclusion criteria were included in the final analysis. All laboratory test parameters only included the data generated within the first 24 hours after the patient entered the intensive care unit (ICU) and the extreme value. Univariate and multivariate logistic regression analyses were performed to analyze the risk factors related to the death of SA-AKI patients within 28 days during hospitalization in the ICU. A total of 3,684 SA-AKI patients were included, including 3,305 patients with low AG (<18 mmol/L) and 379 patients with high AG (≥18 mmol/L). Among these patients, 497 cases (13.5%) died during hospitalization, including 376 cases (11.4%) in the low AG group and 121 cases (31.9%) in the high AG group. Multivariate logistic regression analysis showed that elevated AG increased the risk of death in SA-AKI patients within 28 days during hospitalization in the ICU (odds ratio =1.2, 95% confidence interval: 1.2-1.3). Further analysis showed that the risk of death of SA-AKI patients within 28 days during hospitalization in the ICU was increased when AG ≥14 mmol/L. The relationship between AG level and the risk of death of SA-AKI patients during hospitalization was S-shaped. In clinical practice, AG levels can serve as a valuable predictor of the death risk of SA-AKI patients during hospitalization.

Associations of Metabolic Syndrome and Abdominal Obesity with Anion Gap Metabolic Acidosis among US Adults

Obesity is a recently identified risk factor for metabolic acidosis and anion gap elevations in the absence of CKD. Metabolic acidosis is a treatable condition with substantial adverse effects on human health. Additional investigations are needed to characterize at-risk populations and explore potential mechanisms. We hypothesized metabolic syndrome (MetS) and waist circumference (WC) would be closely associated with this pathology. Adult participants from NHANES 1999-2018 meeting study criteria were compiled as main (n=31,163) and fasting (n=12,860) cohorts. Regression models adjusted for dietary acid, eGFR, and other factors examined associations of WC and MetS features with anion gap metabolic acidosis and its components (serum bicarbonate ≤23 mEq/L and anion gap >95th percentile). Greater WC and MetS features were associated with progressively lower bicarbonate, higher anion gap, and greater odds ratios (OR) of metabolic acidosis (MA) and anion gap metabolic acidosis (AGMA). Compared with the reference, participants with the highest WC had ORs for MA and AGMA of 2.26; 95% CI, 1.96 to 2.62 and 2.89; 95% CI, 1.97 to 4.21; those with three and four versus zero MetS features had ORs for AGMA of 2.52; 95% CI, 1.95 to 2.94 and 3.05; 95% CI, 2.16 to 3.82. Associations of body mass index with outcomes were attenuated or absent after adjustment for WC or MetS. Findings were preserved after excluding eGFR <90 ml/min per 1.73 m2 and albuminuria. A lower MA cutoff (<22 mEq/L) raised the estimate of association between MetS and MA (OR for three and four vs zero features: 3.56; 95% CI, 2.53 to 5.02 and 5.44; 95% CI, 3.66 to 8.08). Metabolic diseases are characterized by metabolic acidosis and anion gap elevations. Metabolic dysfunction may predispose patients without CKD to systemic acidosis from endogenous sources. Comprehensive acid-base analyses may be informative in patients with metabolic diseases.

Association of serum anion gap and risk of long-term mortality in patients following coronary artery bypass grafting: A propensity score matching study.

The present study aimed to explore the relationship between serum anion gap (AG) and long-term mortality in patients undergoing coronary artery bypass grafting (CABG). Clinical variables were extracted among patients undergoing CABG from Medical Information Mart for Intensive Care III (MIMIC III) database. The primary outcome was 4-year mortality following CABG. An optimal cut-off value of AG was determined by the receiver operating characteristic (ROC) curve. The Kaplan-Meier (K-M) analysis and multivariate Cox hazard analysis were performed to investigate the prognostic value of AG in long-term mortality after CABG. To eliminate the bias between different groups, propensity score matching (PSM) was conducted to validate the findings. The optimal cut-off value of AG was 17.00 mmol/L. Then a total of 3162 eligible patients enrolled in this study were divided into a high AG group (≥17.00, n = 1022) and a low AG group (<17.00, n = 2,140). A lower survival rate was identified in the high AG group based on the K-M curve (p < .001). Compared with patients in the low AG group, patients in the high AG group had an increased risk of long-term mortality [1-year mortality: hazardratio, HR: 2.309, 95% CI (1.672-3.187), p < .001; 2-year mortality: HR: 1.813, 95% CI (1.401-2.346), p < .001; 3-yearmortality: HR: 1.667, 95% CI (1.341-2.097), p < .001; 4-year mortality: HR: 1.710, 95% CI (1.401-2.087), p < .001] according to multivariate Cox hazard analysis. And further validation of above results was consistent in the matched cohort after PSM. The AG is an independent predictive factor for long-term all-cause mortality in patients following CABG, where a high AG value is associated with an increased mortality.

An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis

An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis

PSUN139 Leukemoid Reaction in Severe Diabetic Ketoacidosis: An Indicator of Severity or Predictor of Infection?

Abstract Background Acute infectious illness can precipitate episodes of ketoacidosis in patients with diabetes mellitus. For this reason, a diligent search for a focus is essential in the initial evaluation of patients with DKA since patients often appear ill and may have non-specific symptoms. Clinical Case An 18-year old Filipino with Type 1 Diabetes Mellitus sought consult due to abdominal pain. He is on premixed NPH/regular insulin twice daily but was lost to follow-up due to the COVID-19 pandemic. He has no other comorbidities but asserted a prior history of poor compliance with both diet and insulin therapy besides an erratic sleep-wake cycle. Prior to consult, he reported 5 episodes of vomiting associated with generalized abdominal pain. Due to poor appetite, he missed due doses of insulin with subsequent worsening of condition. On admission, he was lethargic with Kussmaul's breathing. Initial vital signs were stable. He had dry lips and oral mucosa, sunken eyeballs and generalized abdominal tenderness. COVID-19 PCR was negative. Serum lipase (8.79, n: 8-78) and CT scan of abdomen were likewise unremarkable. Initial CBG was HIGH with elevated ketones (5.4, n: &amp;lt;0.6) and arterial blood gas revealed a pH of 7.0, pCO2 22, HCO3 incalculable, lactate 3.9, with high anion gap. The initial WBC was high (44.3×109/uL, n: 4.4-11) with 84% neutrophils, 10% lymphocytes, 1% metamyelocytes, and 5% monocytes. Hemoglobin (18.5 g/dl), hematocrit (51.7%) and platelet count (614k/uL) were also elevated. Peripheral blood smear revealed normal cell morphology. Urinalysis revealed elevated specific gravity, marked glycosuria and ketonuria, negative nitrites and leukocyte esterases. Blood specimen were obtained for culture. Therapy was instituted with intravenous fluids, insulin drip and broad spectrum antibiotics. The following day, glucose was 218 mg/dl, pH 7.16, bicarbonate 7.8 meq/L, hematocrit 44%, WBC 25.21×109/uL and platelet count was 401k/uL. LAP score was requested but was unavailable. On the fourth hospital day, the patient was well and tolerating diet, with normalization of blood glucose, WBC 9.87 (85% neutrophils, 10% lymphocytes, 5% monocytes) and control of acidosis. Since cultures were negative and patient was afebrile, antibiotics were discontinued. He was discharged stable on with basal-bolus insulin. Conclusion The association between DKA and leukocytosis in the absence of infection is described in literature. Exact mechanism is unknown but may in part be attributed to increased catecholamine release in response to stress and hemoconcentration from marked dehydration. Studies show a statistically significant relationship between pH, bicarbonate and leukocytes which denotes that WBC in DKA can be an indicator of the severity of ketoacidosis rather than a predictor of infection. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP159 A Rare Case of Pembrolizumab Induced Diabetic Ketoacidosis

Abstract Introduction Immune checkpoint inhibitors (ICI), such as Pembrolizumab, have demonstrated excellent clinical outcomes in numerous solid organ malignancies. However, this new drug comes with unpredictable adverse reactions which are still under review in the medical literature. We are showcasing a cancer patient treated with an ICI and presenting to the hospital in diabetic ketoacidosis (DKA), despite no significant history of a formal diagnosis of Diabetes Mellitus. Case description The patient is a 69 year old male who presented to the hospital with generalized weakness. His past medical history was significant but not limited to, Hypothyroidism, Tobacco use disorder, Stage IV Siewert type 2 gastroesophageal junction adenocarcinoma (cT4N2M1, HER2/FGFR negative, PD-L1 positive) after completion of one year of chemotherapy. He was now undergoing immunotherapy with Pembrolizumab, with his first dose three weeks ago. Reviews of systems including fever, abdominal pain, nausea, vomiting, polyuria, polydipsia were negative. Vital signs were grossly normal. He gave no personal or family history of diabetes. On admission venous blood gas demonstrated a high anion gap metabolic acidosis (pH 7. 096, Blood glucose 762 mg/dL, Anion Gap 29 mmol/L, bicarbonate 9 mmol/L, Plasma osmolality 337 mOsm/kg). Serum Lipase was 23 U/L. HbA1c was found to be 5.9%. Urinalysis was significant for glucose &amp;gt;500 mg/dl and &amp;gt;80 mg/dl of ketones. The physical exam was only remarkable for dry mucous membranes. Given the presentation and lab findings, he was subsequently diagnosed with DKA. The patient was treated with standard guideline therapy for DKA including bolus fluids, maintenance fluids and intravenous (IV) Insulin. The Anion gap closed and glucose decreased to under 200. He was transitioned to a subcutaneous insulin regimen, and discharged on the same. Discussion Based on diagnostic workup and exclusion of probable aetiologies, the patient was diagnosed with pembrolizumab-induced DKA. In the acute care setting, an autoimmune workup was not done in our patient. A meta analysis review of 71 such cases from 56 publications showed the average HbA1c concentration was 7.84% + 1. 0% at presentation. The A1c finding of 5.9%, defined at pre-diabetes, in represents an outlier. Another meta-analysis of such patients demonstrated DKA as the first sign of diabetes in 30 out of 35. The pathophysiology of this side effect of ICI's remains unknown, however several mouse studies have shown PD-1/PD L1 blockade precipitating diabetes in prediabetic non-obese mice. Anti -PD-1 drugs might have the same effect, and the reduction of PD-1 might activate autoreactive T cells, resulting in an autoimmune response against pancreatic islet cells. As the use of immunotherapy is expected to increase, it is essential that clinicians become aware of DKA as a rare and life threatening side effects of immunotherapy and that blood glucose monitoring is strongly considered as a method of prevention. Presentation: No date and time listed

ODP150 Hypertriglyceridemic Induced Acute Pancreatitis with Diabetic Ketoacidosis Treated with Insulin: A Case Report

Abstract Introduction Acute pancreatitis due to hypertriglyceridemia with DKA is a unique entity. The diagnosis of acute pancreatitis in DKA is challenging as most patients present with abdominal pain, and elevated amylase, and lipase are quite common in DKA. Hypertriglyceridemia-induced pancreatitis (HTGP) accounts for 1 to 35 percent of all cases of acute pancreatitis. Pancreatitis may occur in DKA with high anion gap metabolic acidosis. Lack of insulin results in lipolysis with release of free fatty acids. Increased free fatty acids presented to the liver, causes increased VLDL, which inhibits lipoprotein lipase in peripheral tissues and results in elevated triglycerides. Case presentation A 29-year-old morbidly obese male with Asperger's syndrome, prediabetes, and hyperlipidemia presented with a 3-day history of sharp, non-radiating, and progressively worsening right upper abdominal pain, associated with nausea, non-bilious vomiting, and shortness of breath. His past medical history was notable for a prior bout of gallstone pancreatitis, for which he underwent a laparoscopic cholecystectomy. On his arrival in the emergency department, he was afebrile, but tachycardic (HR 139), mildly hypertensive (BP 149/98) with a Kussmaul breathing saturating 98% on room air. His lung sounds were clear but diminished and his abdomen was soft but diffusely tender, without peritoneal signs. Initial laboratory tests showed a neutrophilic leukocytosis of 12K, glucose of 867 mg/dL, hyponatremia (corrected 131), ketonuria, with elevated lipase 1,164 U/L. Venous blood gas showed a pH of 7.18 and PCO2 24 mmHg. He also had severe hypertriglyceridemia with a total triglyceride level of &amp;gt; 9,000 mg/dL. His CT abdomen showed peripancreatic inflammation consistent with acute pancreatitis. He was admitted to the ICU, and initially managed with aggressive intravenous fluids and pain control, then was started on an insulin drip for diabetic ketoacidosis and hypertriglyceridemia. His hospital course was notable for the development of acute kidney injury requiring hemodialysis. His triglyceride level gradually decreased and was 396 U/L on hospital day #9. He was discharged on fenofibrate, Lantus 20 units daily and insulin lispro 10 units with meals. Conclusion Hypertriglyceridemia is an uncommon but a well-established cause of acute pancreatitis leading to significant morbidity and mortality. In this case, a prediabetic patient presented with DKA and further investigation revealed HTGP. There is currently a paucity of data to support an optimal treatment for this condition; however, both insulin and plasmapheresis have been successfully employed. Plasmapheresis helps remove plasma lipoproteins and reduces triglyceride more rapidly than insulin and has been recommended for severe cases. In our case, insulin infusion alone significantly reduced the triglyceride level. Presentation: No date and time listed

PSAT042 Adrenal Insufficiency Associated to Immune Checkpoint Inhibitors

Abstract Background Innovations in management of multiple malignancies have developed throughout the years. Despite benefits in immune checkpoint inhibitors there is an incidence of approximately 9.4% to 10.4% in endocrine immune related disorders. The challenge advocates to promptly recognize the clinical manifestations related to adverse effects. Clinical Case We report a case of a 61-year-old caucasian woman with Metastatic Lung Squamous Cell Carcinoma Stage IV on immunotherapy and radiotherapy who presented to ED with nausea and vomiting for the last 2 weeks. The review of the system pertinent for weight loss 18 pounds in the last 2 months, fatigue and decreased appetite. Medication history pertinent for active Pembrolizumab (started 6 months prior to presentation; cycle every 3 weeks); Radiotherapy (3 cycles) and steroid injections (last dose 1 month prior for bilateral knee pain). Upon arrival vital signs T 36.9C, HR 110/min, RR 18/min, BP 80/60mmHg, and StO2 98%. The physical examination pertinent for an acutely ill patient with tachycardia. Initial laboratory studies showed peripheral eosinophilia 14% (n &amp;lt;6%); high anion gap metabolic acidosis (AG 18), hypokalemia 2.8 mmol/L (n 3.5-5.0mmol/L). The patient was hospitalized with sepsis and intractable vomiting. Gastroenterology evaluated with EGD showed erosive gastritis and reflux esophagitis. CT abdomen with IV contrast showed numerous sclerotic bone lesions and single hepatic lesion suggestive of metastatic disease; unremarkable adrenal glands. Poor response to initial hydration and antibiotics as blood pressure remained fluctuant borderline low prompted evaluation. Random cortisol at 6: 50am showed hypocortisolism (1.6mcg/dl) and TSH 1.290 mcIU/mL (n 0.358- 3.74mcIU/mL); patient was started on stress dose steroids and endocrinology was consulted for suspected adrenal insufficiency. Cosyntropin stimulation test (n &amp;gt;18 mcg/dL) with baseline cortisol levels 1.6mcg/dl and ACTH less than 5mcg/dl; cortisol levels at 30 minutes after 250 mcg of Cosyntropin was 4.3mcg/dl and at 1 hour 6.8mcg/dl, confirming most likely secondary vs primary adrenal insufficiency. Within 24-48 hour stress dose steroids were weaned and the patient was then discharged home with hydrocortisone 20 mg am and 10mg pm for further outpatient management. Conclusion Pembrolizumab is a human programmed death receptor-1-blocking antibody that on October 2015 was FDA approved for treatment of non-small cell lung cancer. Adrenal Insufficiency can cause a broad nonspecific clinical scenario with reported incidence of 0.6-0.7% pembrolizumab-induced AI. This rare clinical entity adrenal insufficiency immune mediated endocrinopathy by pembrolizumab constitutes an emergency that prompts attention for early identification and initial management. Nevertheless increased morbidity and mortality is associated with acute adrenal crisis encouraging physicians to be aware of this particular risk. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Diabetic Ketoacidosis and COVID-19: A Retrospective Observational Study.

Background Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM), mainly type 1 DM. DM is one of the comorbidities recognized as the predictor of the severity in COVID-19-positive patients. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness (COVID-19) has a bidirectional association with DM. DM is a state of chronic inflammatory condition and hyperglycemia that predisposes one to acquire an exaggerated form of COVID-19 infection. Moreover, in recent literature, it has been established that SARS-CoV-2 is capable of directly damaging beta cells of the pancreas, thereby inducing new-onset diabetes in previously non-diabetics. Hence, new-onset diabetes and severe metabolic consequences of pre-existing diabetes, such as DKA, are seen in COVID-19-positive patients. DKA in patients with COVID-19 may increase the risk of mortality and lead to poor prognosis. Methods This retrospective observational study includes 25 patients who presented to our hospital with DKA secondary to COVID-19 infection as a triggering factor. Demographic parameters, medical history, physical examination, laboratory tests including reverse transcriptase polymerase chain reaction test (RT-PCR), chest X-ray, treatment administered, clinical course, and outcomes were recorded. All data were computed and analyzed using SPSS Version 22.0 (IBM Corp., Armonk, NY, USA). Results Of the 25 cases, 14 were females, and a statistically significant difference was seen in the values of blood sugar (367 mg/dL), D-dimer, ferritin, blood urea nitrogen(BUN), and anion gap among males and females (p < 0.050). The males had higher mean values of blood sugar (367 mg/dL), BUN (60.63 mg/dL), D-dimer (1.09 mcg/mL), and ferritin (821.23 mcg/mL) than females, whereas females had a higher anion gap (20.85) than males. A negative correlation was seen between D-dimer and the following biochemical investigations in COVID-19 patients: serum bicarbonate, anion gap, chloride, BUN, creatinine, sodium, potassium, magnesium, and phosphorous. COVID-19 can present with atypical symptoms in patients with high blood sugar levels. Diabetics are more likely to experience effects on multiple organs compared to non-diabetic patients who mainly have lung involvement. Hence, a high degree of suspicion is essential to diagnose DKA early in COVID-19 patients. Conclusion These cases show that DKA can be precipitated by COVID-19 in a significant number of patients and that the presence of diabetes can also exaggerate the underlying COVID-19 infection, a bidirectional relationship. All cases were COVID-19-positive presenting with features characteristic of DKA. SARS-CoV-2 was precipitating factor of DKA. Patients with newly diagnosed diabetes or pre-existing diabetes were equally susceptible to DKA. Due to the high prevalence of both illnesses (DM and COVID-19) in our country, a high level of suspicion is required to detect DKA early and improve the outcome of COVID-19-related life-threatening hyperglycemic consequences.

Radiology Findings in a Case of Acute Methanol Intoxication Complicated with Intracranial Hemorrhage

Aim: Methanol intoxication is rare and it can be fatal. This case report aimed to describe the radiological findings in acute methanol intoxication complicated with intracranial hemorrhage in a young patient. Case Report: A 32 year-old man applied to emergency department with a major complaints of nausea, vomiting, double vision, and confusion. Glascow coma score (GCS) was 7 at the initial referral. Laboratory tests showed high anion gap metabolic acidosis. Acute methanol intoxication was diagnosed by aid of the patient anamnesis. Diffusion-weighted MRI (DW-MRI) showed similar diffusion restriction lesions in the putamen and cingulate gyrus of both cerebral hemispheres. The patient had a cardiac arrest during follow-up in the emergency department. He was converted to sinus rhythm with the interventions, intubated, and taken to the intensive care unit. GCS reduced to 3 during follow- up at the 4th day. Cerebral intraparanchimal hemorrhage at the level of left basal ganglia was observed in the brain computed tomography (CT). He was operated however remained comatose after the operation and died at the 8th day of admission. Conclusion: Possibility of methanol intoxication should be included in the differential diagnosis in patients with altered consciousness, vision disturbances and a high anion gap admitted to the emergency service. DW-MRI may be helpful in diagnosis by detecting symmetrical diffusion restrictions at the basal ganglia. Additionally radiologic methods like CT can be used to determine complications such as bleeding that may occur during the follow-up of the cases.