Diabetic ketoacidosis and hyperosmolar hyperglycaemic syndrome are important hyperglycaemic emergencies seen in patients with diabetes. Occasionally, differentiation between the two conditions can be difficult. We present the case of a patient whose hyperglycaemic emergency was managed in a way that could have adversely influenced the outcome. We also discuss important aspects of the new Joint British Diabetes Societies Guidelines on the management of hyperglycaemic emergencies.

Mucormycosis is an infection caused by filamentous fungi of the Mucorales order. The predisposing factors are mostly diabetic ketoacidosis and severe immunosuppressive conditions such as prolonged neutropenia, steroid or T-cell suppressor therapy, solid organ transplantation or allogeneic hematopoietic stem cell transplantation. Mucormycosis can also occur in immunocompetent patients, especially after trauma, burns or direct inoculation of the fungi (e.g. intravenous drug abuse). The most frequently targeted primary sites of infection are sinuses with a rapid spread to the adjacent tissues including the brain, the lower respiratory tract, the digestive tract and the skin. Mucorales are able to invade the vessels causing hematogenous dissemination, vascular thrombosis and, ultimately, necrosis of the lesions. Clinical and radiological aspects are similar to those observed in other invasive filamentous fungi infections such as invasive aspergillosis, fusariosis or scedosporiosis. CT-scan or MRI are mandatory to assess the extension of the lesions. The diagnosis remains difficult and is often delayed resulting in a poor outcome.

OBJECTIVE:

Excess growth hormone (GH) causes insulin resistance and impaired glucose metabolism. The objective of this study was to clarify the prevalence of ketoacidosis as the initial presenting symptom of acromegaly.

DESIGN AND METHODS:

Data were collected from 860 patients with acromegaly who received pituitary surgery at Toranomon Hospital over the last 32 years, between 1980 and 2011.

RESULTS:

Nine cases had ketoacidosis before being diagnosed with acromegaly, including seven males and two females with a mean ± SD age of 38.8 ± 14.2 years old. Serum GH and IGF-1 levels were 155 ± 203 ng/ml and 9.86 ± 0.68 SDS, respectively, before pituitary surgery and 3.6 ± 1.7 ng/ml and 3.72 ± 3.40 SDS after surgery, respectively. The maximum tumor diameter was 28.2 ± 11.6 mm (ranging from 15 mm to 47 mm, n=8). None of the patients were diagnosed with diabetes mellitus (DM), nor were they positive for antibodies related to type 1 DM. A possible precipitating factor for ketoacidosis in six cases was excessive ingestion of sugar-containing soft drinks. All of the cases had invasive pituitary adenomas. After pituitary surgery, plasma glucose levels were under control without requiring insulin in all cases. Furthermore, six patients did not need oral hypoglycemic agents.

CONCLUSIONS:

Approximately 1% of patients with acromegaly presented with diabetic ketoacidosis as their first clinical condition. (219 words).

BACKGROUND:

We evaluated the incidence, characteristics, and insulin-independency of newly diagnosed Korean type 2 diabetes (T2D) initially presenting with diabetic ketoacidosis (DKA).

METHODS:

We analyzed clinical and biochemical data from diabetic patients presenting with DKA. They were classified into ketosis-prone diabetes (KPD)-T1A (A + β-), KPD-T1B (A - β-), KPD-T2A (A + β+) or KPD-T2B (A - β+) according to the presence or absence of autoantibody and β-cell reserve. Changes in therapy after insulin discontinuation were evaluated for up to 4 years. We also compared clinical and biochemical characteristics between newly diagnosed T2D presenting with DKA and previously-diagnosed T2D presenting with DKA.

RESULTS:

Among 60 newly diagnosed KPD patients, 18, 21, and 21 patients were classified as KPD-T1A, KPD-T1B, and KPD-T2B, respectively. In the KPD-T2B group, both fasting and stimulated C-peptide recovered over 6 months. After 4 years of DKA development, 75% of KPD-T2B subjects no longer required insulin. Compared to previously diagnosed T2D patients presenting with DKA, newly diagnosed KPD-T2B patients tended to be younger, more obese, and showed better insulin secretory function after recovery from DKA.

CONCLUSIONS:

New-onset T2D presenting with DKA was not uncommon among the Korean population. In contrast to previously-diagnosed T2D patients presenting with DKA who showed a progressive decrease in insulin secretory function, new-onset KPD-T2B patients recovered insulin secretory function over time, and insulin independence could be expected. This article is protected by copyright. All rights reserved.

Insulin-dependent juvenile-onset diabetes may occur in the context of rare syndromic presentations suggesting monogenic inheritance rather than common multifactorial autoimmune type 1 diabetes. Here, we report the case of a Lebanese patient diagnosed with juvenile-onset insulin-dependent diabetes presenting ketoacidosis, early-onset retinopathy with optic atrophy, hearing loss, diabetes insipidus, epilepsy, and normal weight and stature, who later developed insulin resistance. Despite similarities with Wolfram syndrome, we excluded the WFS1 gene as responsible for this disease. Using combined linkage and candidate gene study, we selected ALMS1, responsible for Alström syndrome, as a candidate gene. We identified a novel splice mutation in intron 18 located 3 bp before the intron-exon junction (IVS18-3T>G), resulting in exon 19 skipping and consequent frameshift generating a truncated protein (V3958fs3964X). The clinical presentation of the patient significantly differed from typical Alström syndrome by the absence of truncal obesity and short stature, and by the presence of ketoacidotic insulin-dependent diabetes, optic atrophy and diabetes insipidus. Our observation broadens the clinical spectrum of Alström syndrome and suggests that ALMS1 mutations may be considered in patients who initially present with an acute onset of insulin-dependent diabetes.European Journal of Human Genetics advance online publication, 8 May 2013; doi:10.1038/ejhg.2013.87.

Mucormycosis is a life-threatening fungal infection almost uniformly affecting diabetics in ketoacidosis, other form of acidosis, and/or immunocompromised patients. Inhalation of Mucorales spores provides the most common natural route of entry into the host. In this study, we developed an intratracheal instillation model of pulmonary mucormycosis that hematogenously disseminates into other organs using diabetic ketoacidotic (DKA) or cyclophosphamide/cortisone acetate-treated mice. Varying degrees of lethality was achieved for the DKA or cyclophosphamide/cortisone acetate-treated mice when infected with different clinical isolates of Mucorales. In both DKA and cyclophosphamide/cortisone acetate models, liposomal amphotericin B (LAmB) or posaconazole (POS) treatments were effective in improving survival, reducing lungs and brain fungal burdens and histologically resolving the infection when compared with placebo. These models can be used to study mechanisms of infection, develop immunotherapeutic strategies and evaluate drug efficacies against life threatening Mucorales infections.

AIM:

Low-dose intravenous infusions of regular insulin, usually initiated in the emergency department and continued in the intensive care unit (ICU), are the standard care for patients with diabetic ketoacidosis (DKA) to ensure rapid resolution of hyperglycaemia and ketoacidosis. Several studies have evaluated whether subcutaneous injections of the rapid-acting analogue insulin lispro may be an alternative to intravenous insulin infusion for avoiding ICU admissions of uncomplicated DKA cases.

METHODS:

This review summarizes the current clinical evidence for the effectiveness and safety of subcutaneous insulin lispro injections in non-severe DKA patients. Relevant studies were identified by a systematic literature search through the PubMed database.

RESULTS:

To date, four small randomized studies (156 patients overall; three studies in adults and one in paediatric patients with diabetes) have directly compared subcutaneous insulin lispro injections every 1-2h vs continuous intravenous infusions of regular insulin. Patients with severe complications were excluded. In all studies, the mean time to resolution of DKA was similar in both treatment groups [range (three studies): lispro 10-14.8h; regular insulin 11-13.2h]. The mean time to resolution of hyperglycaemia, total insulin doses required, number of hospitalization days and number of hypoglycaemic episodes were similar in both treatment groups; no severe complications or DKA recurrences were reported, and one study showed a 39% cost reduction for the insulin lispro group.

CONCLUSION:

In patients with mild-to-moderate DKA, subcutaneous injections of insulin lispro every 1-2h offer a feasible alternative to continuous intravenous infusions of regular insulin, and should now be evaluated in larger, more appropriately powered studies.

Maternal mortality in sub-Saharan Africa has remained high and this is a reflection of the poor quality of maternal services.To determine the causes, trends, and level of maternal mortality rate in Abakaliki, Ebonyi.This was a review of the records of all maternal deaths related to pregnancy over a ten-year period, that is, January 1999 to December 2008. Relevant information on number of deaths, booking status, age, parity, educational level of women, mode of delivery, and causes of death were extracted and analyzed.During the study period, there were 12,587 deliveries and 171 maternal deaths. The maternal mortality ratio (MMR) was 1,359 per 100,000 live births. The trend over the period was lowest in 2008 and highest in 1999 with an MMR of 757 per 100,000 live births and 4,000 per 100,000 live births, respectively. There was a progressive decline in the MMR over the period of study except in the years 2003 and 2006, when the ratio spiked a little, giving an MMR of 1,510 per 100,000 live births and 1,290 per 100,000 live births, respectively. The progressive decline in maternal mortality corresponded with the time that free maternal services were introduced. Hemorrhage was the most important cause of maternal death, accounting for 23.0% (38/165), whereas diabetic ketoacidosis, congestive cardiac failure, and asthma in pregnancy were the least important causes of maternal deaths, each accounting for 0.6% (1/165). Majority of the maternal deaths occurred in unbooked patients (82.4% (136/165)), whereas 17.6% (29/165) of the deaths occurred in booked cases. Forty-seven (28.5% (47/165)) patients died following a cesarean section, 8.5% (14/165) died as a result of abortion complications, and 10.9% (18/165) died undelivered. Seventy-seven (46.7% (77/165)) of the maternal death patients had no formal education. Low socioeconomic status, poor educational level, and grand multiparity were some of the risk factors for maternal mortality.There was a decline in MMR during the period of study. The free maternal health services and adequate staff recruitment, which may have contributed to the observed decline in maternal mortality, should be sustained in developing countries.

A 23-year-old woman with a history of type 2 diabetes and non-compliance presented to the emergency department with abdominal epigastric pain and nausea. Laboratory examination revealed a mild ketoacidosis while an abdominal CT scan performed the following day demonstrated a severe acute pancreatitis of the body and tail (Balthazar grade E) despite normal amylase serum levels on admission. The presence of a lactescent serum was the clue to an extremely high triglyceride level (>10 000 mg/dl) causing the pancreatitis. The hypertriglyceridaemia itself was attributed mainly to the diabetic ketoacidosis. There was no family history of hypertriglyceridaemia. The triad consisting of diabetic ketoacidosis, hypertriglyceridaemia and acute pancreatitis is an unusual presentation of poorly controlled diabetes which can occur in type 1 as well as type 2 diabetic adults and children. Treatment with intravenous insulin and hydration successfully resolved the ketoacidosis and hypertriglyceridaemia and reversed the episode of acute pancreatitis.