Diabetic Ketoacidosis Revealing a Severe Hypertriglyceridemia and Acute Pancreatitis in Type 1 Diabetes Mellitus

Abstract

Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication occurring in patients with diabetes, especially in patients with type 1 diabetes (T1D), due to an insulin deficiency. Moderate hypertriglyceridemia is commonly observed in DKA but severe hypertriglyceridemia with a triglyceride level exceeding 10g/L is very rarely reported. We report a case of a 14-year-old boy who had type 1 diabetes for 4 years treated with insulin therapy, also having adrenal insufficiency treated with hydrocortisone who presented with ketoacidosis and excruciating abdominal pain. Investigations revealed hypertriglyceridemia at 64g/L, lipasemia at 1000 U/L, and stage E pancreatitis on abdominal CT. The patient was treated with intravenous insulin, rehydration, and fenofibrate with good clinical and biological evolution. Severe hypertriglyceridemia causing pancreatitis in type 1 diabetes mellitus is a rare but very serious complication of DKA in children.

Whole exome sequencing identifies three novel gene mutations in patients with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis

“…Chylomicrons transport triglycerides and cholesterol from the small intestine to other tissues, and VLDL transports endogenous triglycerides to peripheral tissues and releases FFAs after lipase hydrolysis. Insulin deficiency also increases the release of FFAs from adipose tissues and muscles, thereby accelerating the formation of VLDL in the liver and leading to hypertriglyceridemia 21 . Severe hypertriglyceridemia‐related pancreatitis was closely associated with diabetes.…”

“…9 Moderate hypertriglyceridemia is commonly observed in combination with DKA, but severe hypertriglyceridemia with a triglyceride level exceeding 1000 mg/dL is very rarely reported. 21 In this study, we present a case series of six patients with the triad of AP, severe hypertriglyceridemia, and DKA.…”

“…Insulin deficiency also increases the release of FFAs from adipose tissues and muscles, thereby accelerating the formation of VLDL in the liver and leading to hypertriglyceridemia. 21 Severe hypertriglyceridemia-related pancreatitis was closely associated with diabetes. Extreme hypertriglyceridemia and high triglyceride levels were independent long-term predictors of recurrent pancreatitis.…”

What a type of diabetes is having your patient? Challenges in diagnosing diabetes in children and adolescent – case report

“…Finally, in DKA, the deficiency of insulin activates lipolysis in adipose tissue releasing increased free fatty acid (FFA), which accelerates formation of very low density lipoprotein (VLDL) in the liver. Additionally, reduced activity of lipoprotein lipase in peripheral tissue decreases removal of VLDL from the plasma, resulting in hypertriglyceridemia which may led to acute pancreatitis [7]. On the one hand, her family history was positive for T2D and at least one affected parent is present in one-half to three-quarters of children with T2D, compared to less than 10% of children with T1D [8].…”

Acute pancreatitis concomitant with diabetic ketoacidosis: a cohort from South China

“…It has been infrequently reported in prior literature that DKA can coexist with AP. [1][2][3][4][5] AP is present in approximately 11% of DKA patients, 6 while the DKA prevalence in AP patients is approximately 1.2% to 26.4%. 7 A significantly higher mortality rate was found in patients with concomitant DKA and AP compared with AP-only patients.…”