An Unusal Cause Of Diabetic Ketoacidosis

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Diabetic ketoacidosis (DKA) is one of the diagnosis needing ICU management. Leading causes include sepsis, non-compliance, acute gastroenteritis followed by myocardial infarction, acute stroke. In one third of the cases there is no etiology. CASE PRESENTATION: 66-year female with a history of type I diabetes mellitus admitted to the hospital for DKA. The patient was brought in by the family with history suggesting a healthy compliant patient on an insulin pump for 4 years. She had no recent illness and had a recent annual physical exam suggesting no other co-morbidities. She was found unresponsive on her bed by her family with a last known well time of 18 hours. Vitals on arrival were in normal limits. Physical exam showed abdominal tenderness and a stiff patient with minimal response to verbal and noxious stimuli. She was found to be Influenza positive and laboratory values showed DKA and a lactate of 10, which improved with aggressive fluid hydration and routine DKA management. She was encephalopathic with decorticate posturing and therefore a CT head was performed which showed multiple lesions in the brain with an MRI confirming acute stroke. She was also noted to have abdominal tenderness on examination and a CT abdomen showing splenic infarcts and ischemic colitis with filling defects in the superior mesenteric artery. Intravenous heparin was initiated and further workup for embolic source revealed a atrial myxoma. DISCUSSION: Although the patients with DKA are known to be encephalopathic, decorticate posturing noted on the physical examination can guide towards the etiology of DKA in a compliant patient. Decorticate posturing in DKA is known to be a sign of cerebral edema, but a stroke should also be on the differentials. Influenza infection is known to have a procoagulant nature [1]. DKA is also known to be a procoagulant state [2,3] and puts the patient at further risk if anticoagulation is not started simultaneously owing to permanent neurological deficits. Our patient has a complicated etiology of atrial myxoma, which we think was the embolic source and as per mentioned, the procoagulant state of influenza is the tipping point for the patient's stroke, which led to her DKA and worsened her condition to be presented to the ED with DKA having a decorticate posturing. CONCLUSIONS: Identifying the etiology of DKA is of utmost importance and the workup for etiology should begin from the time of admission along with the management of DKA and a complete neurological examination to identify focal neurological deficits can help use guide towards the diagnosis. Reference #1: INFLUENZA B-INDUCED CATASTROPHIC HYPERCOAGULABLE RESPONSEKallur, Lakshmi; Marco, Sean; Houshmand, Farnaaz; Mazer, MarkCritical Care Medicine: January 2018 - Volume 46 - Issue 1 - p 212 Reference #2: Diabetic Ketoacidosis Promotes a Prothrombotic StateG. F. Carl , Ph.D.,William H. Hoffman , M.D.,Gregory G. Passmore , Ph.D.,Edward J. Truemper, M.D.,Alton L. Lightsey , M.D.,Philip E. Cornwell , Ph.D. &Mary H. Jonah , M.T. Journal: Endocrine Research Volume 29, 2003 - Issue 1Pages 73-82 | Published online: 07 Jul 2009 Reference #3: Changes in the factor VIII complex in diabetic ketoacidosis: evidence of endothelial cell damage? M. Greaves, C. Pickering, G. Knight, A. J. M. Boulton, J. Ball, J. D. Ward & F. E. Preston Diabetologia volume 30, pages160–165(1987) DISCLOSURES: No relevant relationships by Radha Kishan Adusumilli, source=Web Response No relevant relationships by Ankita Aggarwal, source=Web Response No relevant relationships by Raashi Chawla, source=Web Response No relevant relationships by Yashar Eshman, source=Web Response No relevant relationships by Manishkumar Patel, source=Web Response