Acute Acute DiabetesDiabetesCase BCase B

By:By:Abdullah OsmanAbdullah OsmanChristine TanzilChristine Tanzil

Ayse TogacAyse Togac

Jack (51 years) was admitted to hospital

with a 24 hour history of drowsiness.

Medical HistoryMedical History

Cardiomyopathy with aortic Cardiomyopathy with aortic and mitral regurgitationand mitral regurgitation

HypertensionHypertension

Ischaemic heart diseaseIschaemic heart disease

MedicationsMedications Frusemide 40mg MANEFrusemide 40mg MANE

A loop diuretic indicated for hypertension.A loop diuretic indicated for hypertension.

Lisinopril 20mg DAILYLisinopril 20mg DAILY An angiotensin converting enzyme inhibitor An angiotensin converting enzyme inhibitor

indicated for hypertension.indicated for hypertension.

Aspirin 100mg DAILYAspirin 100mg DAILY An anti-platelet drug indicated for secondary An anti-platelet drug indicated for secondary

prevention in ischaemic heart disease.prevention in ischaemic heart disease.

Glyceryl trinitrate 600mcg SL PRNGlyceryl trinitrate 600mcg SL PRN A nitrate indicated for angina (IHD)A nitrate indicated for angina (IHD)

On examination to the hospital he was:

•Unconscious

•Hyperventilating

•Dehydrated

•BP = 80/40

•Pulse = 120

Vigorous rehydration, electrolyte replacement and

insulin therapy were administered.

Urinalysis was positive for glucose but negative for

ketone bodies.

A diagnosis of NKHC was suspected.

What is What is NKHC?NKHC?

PART 1PART 1

What is NKHC?What is NKHC?

Non-ketotic Hyperosmolar ComaNon-ketotic Hyperosmolar Coma A syndrome characterized by A syndrome characterized by

hyperglycaemia, extreme dehydration, hyperglycaemia, extreme dehydration, and hyperosmolar plasma leading to and hyperosmolar plasma leading to impaired consciousness, sometimes impaired consciousness, sometimes accompanied by seizures.accompanied by seizures.

Non-ketotic hyperosmolar coma Non-ketotic hyperosmolar coma (NKHC) is a complication of type II DM (NKHC) is a complication of type II DM and has a mortality rate of over 50%.and has a mortality rate of over 50%.

What are the signs and What are the signs and symptoms? symptoms?

In some patients, an infection, In some patients, an infection, particularly pneumonia or gram-particularly pneumonia or gram-negative sepsis, is an initiating negative sepsis, is an initiating event; but NKHC can also occur event; but NKHC can also occur when patients with undiagnosed or when patients with undiagnosed or neglected type II DM receive drugs neglected type II DM receive drugs that impair glucose tolerance (e.g., that impair glucose tolerance (e.g., Glucocorticoids) or increase fluid Glucocorticoids) or increase fluid loss (e.g., diuretics). loss (e.g., diuretics).

Diagnostic features of Diagnostic features of NKHCNKHC

The consistent and diagnostic The consistent and diagnostic features of NKHC are CNS features of NKHC are CNS alterations, extreme alterations, extreme hyperglycaemia, dehydration and hyperglycaemia, dehydration and hyperosmolarity, mild metabolic hyperosmolarity, mild metabolic acidosis without marked acidosis without marked hyperketonemia, and pre-existing hyperketonemia, and pre-existing chronic renal failurechronic renal failure

Continued…..Continued….. The state of consciousness at The state of consciousness at

presentation varies from mental presentation varies from mental cloudiness to coma. The plasma glucose cloudiness to coma. The plasma glucose is usually in the range of 55.5 mmol/L. is usually in the range of 55.5 mmol/L. The calculated serum osmolality on The calculated serum osmolality on admission is about 400 mmol/L, whereas admission is about 400 mmol/L, whereas the normal level is around 280mmol/L. the normal level is around 280mmol/L.

The mean fluid deficit is about 22% of The mean fluid deficit is about 22% of the total body water, or about 10 L, and the total body water, or about 10 L, and acute circulatory collapse is a common acute circulatory collapse is a common terminal event in NKHCterminal event in NKHC

Do the results Do the results support the support the diagnosis?diagnosis?

PART IIPART II

JACK’S RESULTSJACK’S RESULTS

NaNa 143143 135-135-145mmol/L145mmol/L

KK 4.44.4 3.8-3.8-4.9mmol/L4.9mmol/L

HbHb 18.218.2 13-18g/dL13-18g/dL

UreaUrea 3232 3-8mmol/L3-8mmol/L

pHpH 7.357.35 7.36-7.447.36-7.44

GlucoseGlucose 6565 3-8mmol/L3-8mmol/L

AmylaseAmylase 295295 70-400U/L70-400U/L

Creatine Creatine kinasekinase

28502850 60-30060-300

OsmolalityOsmolality 480480 265-265-285mmol/L285mmol/L

SIGNS OF NON-KETOTIC SIGNS OF NON-KETOTIC HYPEROSMOLAR COMAHYPEROSMOLAR COMA

CNS alterationsCNS alterations Increased HRIncreased HR DehydrationDehydration Decreased BPDecreased BP Increased tempIncreased temp ThirstThirst

DIAGNOSING NKHCDIAGNOSING NKHC

BGL >50mmol/LBGL >50mmol/L pH >7.3pH >7.3 Bicarbonate slightly decreasedBicarbonate slightly decreased Na and K basically normalNa and K basically normal Large increase in BUNLarge increase in BUN Serum Osmolality > 320mmol/lSerum Osmolality > 320mmol/l

JACK’S RESULTSJACK’S RESULTS

UnconsciousUnconscious HyperventilatingHyperventilating DehydratedDehydrated BP of 80/40BP of 80/40 Pulse Rate of 120Pulse Rate of 120

i.e. indicative of NKHCi.e. indicative of NKHC

JACK’S RESULTSJACK’S RESULTS

JacJackk

Normal Normal RangeRange

Diagnosis of Diagnosis of NKHCNKHC

UreaUrea 3232 3-8mmol/L3-8mmol/L Large Large IncreaseIncrease

OsmolalOsmolalityity

480480 265-265-285mmol/L285mmol/L

Large Large IncreaseIncrease

GlucoseGlucose 6565 3-8mmol/L3-8mmol/L Large Large IncreaseIncrease

pHpH 7.357.35 7.36-7.447.36-7.44 >7.3>7.3

NaNa 143143 135-135-145mmol/L145mmol/L

NormalNormal

KK 4.44.4 3.8-3.8-4.9mmol/L4.9mmol/L

NormalNormal

What are the What are the other acute other acute

presentations of presentations of diabetes apart diabetes apart from NKHC?from NKHC?

PART IIIPART III

Diabetic Ketoacidosis Diabetic Ketoacidosis (DKA)(DKA)

Mainly occurs in type I diabetics.Mainly occurs in type I diabetics. Ketosis is a condition that is characterised by an elevated serum Ketosis is a condition that is characterised by an elevated serum

level of ketone bodies. The ketone bodies are generally found in level of ketone bodies. The ketone bodies are generally found in blood, urine and tissues.blood, urine and tissues.

Occurs where there are high levels of blood glucose and glucagon Occurs where there are high levels of blood glucose and glucagon levels.levels. high glucagon levels result in an increased production of ketones.high glucagon levels result in an increased production of ketones.

Occurs where there are low levels of insulin.Occurs where there are low levels of insulin. Low insulin levels result in increased ketone production.Low insulin levels result in increased ketone production.

The patients generally present with impaired consciousness, The patients generally present with impaired consciousness, dehydration, hyperventilation, low pH, hyperkalemia, potassium dehydration, hyperventilation, low pH, hyperkalemia, potassium deficiency, hyperphosphatemia and phosphate depletion and deficiency, hyperphosphatemia and phosphate depletion and sodium depletion.sodium depletion. K+ and Phosphate depletion due to urinary lossK+ and Phosphate depletion due to urinary loss The acidosis is partly compensated by hyperventilation.The acidosis is partly compensated by hyperventilation.

Occurs where there are any changes in hormones (adrenaline, Occurs where there are any changes in hormones (adrenaline, cortisol and growth hormone) result in a mobilisation of free fatty cortisol and growth hormone) result in a mobilisation of free fatty acids from adipose tissue and result in an increase in ketone body acids from adipose tissue and result in an increase in ketone body production in the liver.production in the liver.

Hypoglycaemic ComaHypoglycaemic Coma

Glucose levels are generally <2.5mmol/LGlucose levels are generally <2.5mmol/L Insulin levels are elevated or normal and Insulin levels are elevated or normal and

therefore there are generally no ketone therefore there are generally no ketone bodies present.bodies present.

Patients present with symptoms of anxiety, Patients present with symptoms of anxiety, fainting, hunger, sweating and headache.fainting, hunger, sweating and headache.

Hypoglycaemia may be caused by fasting Hypoglycaemia may be caused by fasting or by other medications such as insulin, or by other medications such as insulin, sulphonylureas, salicylates and alcohol sulphonylureas, salicylates and alcohol consumption.consumption.

InsulinomaInsulinoma

There are generally low blood glucose levels.There are generally low blood glucose levels. Male < 55mg/dLMale < 55mg/dL Female <35mg/dLFemale <35mg/dL

There are generally elevated insulin levels.There are generally elevated insulin levels. Therefore generally there are no ketone bodies Therefore generally there are no ketone bodies

present.present. Diagnosis is confirmed by an elevated plasma Diagnosis is confirmed by an elevated plasma

insulin levels of >15mU/L and proinsulin levels of insulin levels of >15mU/L and proinsulin levels of >40fmol/L.>40fmol/L.

Levels of insulin may be mimicked by too Levels of insulin may be mimicked by too much use of oral sulfonylurea's or insulin use.much use of oral sulfonylurea's or insulin use.