Background: Diabetic Ketoacidosis is known as an inflammatory state. Review of literature shows a number of cases of mesenteric ischemia described in the adolescent and adult population with long term IDDM. There have also been publications and reports of pediatric patients developing strokes.(1) However there are no reports of adults presenting with the first episode of DKA associated with acute mesenteric ischemia. The hypercoagulable state of DKA has been attributed to decreased activity of protein C and S. VWF activity and factor have also been shown to be increased prior to initiation of treatment and activity was shown to be continuously increased even at 120 hours after treatment. The prothrombotic state and activation of the vascular endothelium is thought be secondary to increased vWF and the decreased levels of protein C activity and of free protein S.(2) Clinical case: 37 year old man with no known past medical history presented with a few day history of abdominal pain, nausea and vomiting. He was found to be significantly hyperglycemic at 635mg/dL, acidotic with bicarb level of 6mEq/L and ABG Ph of 6.9. He was also found to have elevated B hydroxybutyrate >5.5mmol/L and ketones in urine. CT scan of the abdomen was nonspecific and he was started on an insulin drip and the treatment protocol for DKA. His lactic acidosis resolved from 3.9mmol/L to 0.8mmol/L. He clinically improved and started tolerating liquids and oral diet within a few hours. 36 hours after presentation, the patient reported recurrence of abdominal pain and nausea. Lab work up showed recurrence of lactic acidosis. His pain intensified and a repeat ct scan of the abdomen showed multiple dilated fluid filled loops with a transition point in the mid abdomen. Mesenteric vein gas was also noted which was concerning for SMA thrombosis and gut ischemia. Emergent surgical consultation was requested and the patient underwent exploratory laparoscopy and laparotomy which showed extensive small bowel ischemia with 135cm of unaffected small bowel. Patient underwent bowel resection and SMA arteriogram. He then required repeat surgery for inspection of bowels and closure of abdomen. Patient was liberated from the ventilator, and as his bowel function recovered, he was restarted on a clear liquid diet and advanced to a regular diabetic diet prior to discharge. Conclusion: This is a rare case of mesenteric ischemic in the setting of the first episode of DKA in an adult man. Both DKA and mesenteric ischemia are potentially fatal. Prognosis depends on detection and early treatment of both conditions. Persistent or recurrent abdominal pain, nausea and vomiting should raise concern for thrombotic and inflammatory complications of DKA. 1. Ho J, Pacaud D, Hill MD, Ross C, Harniwka L, Mah JK. Diabetic ketoacidosis and pediatric stroke. CMAJ 2005;172(3):327–8. [PMC free article] [PubMed] 2.Carl GF, Hoffman WH, Passmore GG, Truemper EJ, Lightsey AL, Cornwell PE, Jonah MH. Diabetic ketoacidosis promotes a prothrombotic state. Endocr Res. 2003 Feb;29(1):73–82. doi: 10.1081/erc-120018678. PMID: 12665320.

28 year old compliant man with a history of type I diabetes mellitus and primary hypothyroidism, presented to the ER for a two day history of fatigue, nausea, vomiting and abdominal pain. On physical exam, patient was drowsy with a dry skin and normal temperature. Kussmaul respirations were noted and HR was 120bpm. Laboratory workup showed glucose of 747, positive serum acetone, creatinine 4, and metabolic acidosis with anion gap of 64. ABG revealed the following: pH 7.071, PaO 2 117.3, PaCO 2 20, and HCO 3 5.8 meq/L. Appropriate treatment for DKA was initiated and despite adequate fluid resuscitation, patient remained tachycardic. EKG showed sinus tachycardia. Upon further questioning the patient, he reported those 2 weeks prior, he started experiencing erectile dysfunction and decided on his own to increase his dose of levothyroxine from 300 to 600 mcg per day. Thyroid panel was ordered and it showed a TSH of 0.014 and FT4 of 3.1 so beta blocker was started. Twelve hours later, his DKA resolved as well as his acute renal failure and he became hemodynamically stable. Conclusion: Thyroid storm and DKA are both potentially fatal especially that DKA may obscure the typical clinical presentation of thyrotoxicosis. Prognosis varies depending on whether or not these conditions are detected early and treated sufficiently. Persistent tachycardia following correction of dehydration in aseptic patients with DKA should raise the possibility of thyrotoxicosis especially for those known to have a thyroid disease. Diabetic patients taking thyroid hormones should be made aware of the complications that may result from excess doses.