An Untoward Case of Diabetic Ketoacidosis and Hypertriglyceridemia Pancreatitis in a Young Type 2 Diabetes Patient

Introduction:
In the US, every year, there are around 60 cases of Diabetic ketoacidosis (DKA) admissions seen per 10,000 admissions and out of which the mortality rate is only 0.38%. The enigmatic triangle of diabetic ketoacidosis (DKA) with concurrent hypertriglyceridemia-induced acute pancreatitis is an uncommon phenomenon. This rare combined presentation can lead to detrimental outcomes in diabetes mellitus (DM) patients.

Case Description:
The patient is a 21-year-old male with a previous history of prediabetes who presents to the ED with complaints of epigastric abdominal pain, nausea, and non-bloody vomiting for two days. In the ED, afebrile, tachycardic, and tachypneic saturating well on room air. His blood pressure was stable. His vitals, physical examination findings were normal. On admission, patient was dehydrated with hemoglobin 19.7, WBC count 25k, BUN 37, creatinine 1.83. Blood glucose 833. His hemoglobin A1c 12.4, positive ketones in serum and urine, anion gap 32, bicarbonate 8, pH of 7.16. TSH 0.64. His levels of lipase 13k and triglycerides 1428. Sepsis workup was negative for any source of infection. Fluid resuscitation to up to 5 liters of fluids was given, was started on an insulin drip. The patient was transferred to ICU and was still tachycardic in the 180s, so adenosine, metoprolol, and diltiazem were given. It improved to the 150s. An hour later, he was more confused and was intubated for airway protection. Around 30 minutes later, he went into cardiac arrest and achieved ROSC. He was then on maximum vasopressor support and eventually had two more cardiac arrests and passed away.

Discussion:
Even though the management for both DKA and hyperlipidemia pancreatitis may be similar with insulin administration, when they present together, it can be catastrophic and lead to systemic complications like SIRS, pancreatic necrosis, abdominal compartment syndrome, and even death. This is an example of how this combination led to severe outcomes cascading over the hospital course, which led to the mortality of a young type 2 DM patient.