Aims Diabetic ketoacidosis (DKA) is an emergency with high morbidity and mortality. This study examined patient factors associated with hospitalization for recurrent DKA. Methods Characteristics of 265 subjects admitted for DKA at Hennepin County Medical Center between January 2017 and January 2019 were retrospectively analyzed. Differences between subjects with a single admission versus multiple were reviewed. Results Forty-eight out of 265 patients had recurrent DKA. Risk factors included African American race (adjusted odds ratio (aOR) versus white non-Hispanic = 4.6, 95% CI 1.8–13, p = 0.001) or other race/ethnicity (aOR = 8.6, 2.9–28, p < 0.0001), younger age (aOR 37-52y versus 18-36y = 0.48, 0.19–1.16, p = 0.10; aOR 53-99y versus 18-36y = 0.37, 0.12–0.99, p = 0.05), type 1 diabetes mellitus (aOR = 2.4, 1.1–5.5, p = 0.04), ever homeless (aOR = 2.5, 1.1–5.4, p = 0.03), and drug abuse (aOR = 3.2, 1.3–7.8, p = 0.009). DKA cost a median of $29,981 per admission. Conclusions Recurrent DKA is costly, and social determinants are strong predictors of recurrence. This study highlights the need for targeted preventative care programs.

Objective: We report a new, life-threatening adverse effect of zoledronic acid. One of the adverse effects of zoledronic acid is acute phase reaction (APR). Mild APR is characterized by arthralgia, myalgia, headache, and fever, which are usually self-limiting. Here, we present a case of severe systemic inflammatory response syndrome (SIRS) following zoledronic acid infusion, leading to multi-organ failure. Methods: A 63-year-old female presented to the emergency department with fever, headache, and myalgia within hours after zoledronic acid infusion. Approximately 24 hours later, she developed progressive weakness and confusion. She was febrile, tachycardic, and tachypneic on presentation. Subsequently, she developed acute respiratory distress syndrome, stress or Takotsubo cardiomyopathy, shock with hypotension, and acute tubular necrosis with acute kidney failure. Results: All infectious work-up was unrevealing. She was diagnosed with severe SIRS leading to multiorgan failure. She needed aggressive supportive therapies, including mechanical ventilation, multiple vasopressors, and renal replacement therapy. She was treated with systemic steroids. She gradually improved over the next 4 weeks. Conclusion: Mild APRs are common with administration of nitrogen-based bisphosphonates. However, to date, severe life-threatening APR as seen in the above-mentioned case has not been reported. It is important for clinicians to be aware of the possibility of such adverse effects. This case highlights the need for further investigation related to underlying mechanisms of APR by bisphosphonates and identification of patients at risk so that alternative treatments may be considered. (AACE Clinical Case Rep. 2018;4:e26-e29) Abbreviations: APR = acute phase reaction; FPPS = farnesyl pyrophosphate synthase; IPP = isopentenyl pyrophosphate; IV = intravenous; UTI = urinary tract infection

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Summary We report a rare case of biopsy-proven isolated immunoglobulin G4 (IgG4)-related hypophysitis and Rathke’s cleft cyst (RCC) presenting as panhypopituitarism. A 54-year-old Caucasian female presented with symptoms of slurred speech, altered mental status, polyuria and polydipsia and was found to have panhypopituitarism. Brain MRI showed a suprasellar mass with suspected intralesional hemorrhage. She underwent trans-sphenoidal resection due to MRI evidence of compression of the optic chiasm and left optic nerve. Preoperatively, she was started on hydrocortisone, levothyroxine and desmopressin. Histopathology demonstrated a RCC with adjacent lymphoplasmacytic hypophysitis with numerous IgG4-immunoreactive plasma cells. Hydrocortisone was stopped at 10 months after confirming hypothalamic-pituitary-adrenal (HPA)-axis recovery and desmopressin was stopped at 1 year. There was recurrence of a cystic mass at 1 year follow-up. Over 4 years of follow-up, she continued to require levothyroxine, and the mass remained stable in size. In order to begin to understand how this case’s unique histopathological presentation influences clinical presentation, pituitary imaging and prognosis, we present an accompanying literature review. Learning points Isolated IgG4 hypophysitis and coexisting Rathke’s cleft cyst is a rare condition, which presents a diagnostic challenge. Recognizing its characteristic features can assist with early recognition and initiation of therapy to promote optimal outcomes. Further studies investigating the mechanisms promoting co-occurrence of these entities and their effect on prognosis are needed.