Extreme Insulin Resistance in a Patient with Diabetes Ketoacidosis and Acute Myocardial Infarction

Abstract

Hyperglycemia is common in hospitalized patients and associated with adverse clinical outcomes. In hospitalized patients, multiple factors contribute to hyperglycemia, such as underlying medical conditions, pathophysiological stress, and medications. The development of transient insulin resistance is a known cause of hyperglycemia in both diabetic and nondiabetic patients. Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance. Here, we report a case of prolonged course of extreme insulin resistance in a patient admitted with diabetic ketoacidosis (DKA) and acute myocardial infarction (MI). The main purpose of this paper is to review the literature to identify the underlying mechanisms of extreme insulin resistance in a patient with DKA and MI. We will also briefly discuss the different clinical conditions that are associated with insulin resistance and a general approach to a patient with severe insulin resistance.

Methanol Poisoning as a Trigger for the Presentation of Diabetes Mellitus: A Case Report

“…High osmolar gap is expected in this poisoning; on the other hand, the increased metabolism of fatty acids and ketoacids (acetoacetate and beta-hydroxybutyrate) accumulation lead to diabetic ketoacidosis [5]. This situation is more common in type 1 diabetes because of the discontinuation of insulin or physical stress such as pancreatitis [6], gastroenteritis [7], and myocardial infarction [8], which a transient increased need to insulin occurs in these conditions. Clinical manifestations (for example, nausea and vomiting, abdominal pain, impaired visual acuity, dyspnea, tachycardia, and tachypnea) in these situations are very similar; there are also several similarities in paraclinical manifestations such as hyperglycemia, metabolic acidosis, and hyperamylasemia [9].…”

Cardiac arrest from acute myocardial infarction complicated with sodium-glucose cotransporter 2 inhibitor-associated ketoacidosis

“…There have been several reports of acute myocardial infarction complicated with DKA [7,8]. Although the mechanism remains unclear, it is known that DKA precipitates a prothrombotic environment, secondary to hyperviscosity and increased coagulation activity [9].…”

A Male with Extreme Subcutaneous Insulin Resistance: A Case Report

“…Severe insulin resistance should be suspected when an individual requires more than 2 units/kg/day of insulin [3]. A condition where an individual insulin requirement is more than 3 units/kg/day is known as extreme insulin resistance [4].…”

“…Though mechanism unknown, insulin degradation in subcutaneous adipose tissue and muscle has been reported [6,7]. Established mechanisms of insulin resistance include genetic defects in insulin receptors, insulin receptor antibodies and interference with intracellular insulin action due to the excess of counter-regulatory hormones of inflammatory cytokines and increased insulin clearance [3]. …”

“…We could not measure insulin level of the patient while infusing insulin intravenously due to lack of facility. It would indicate the clearance rate as studies suggest that increased insulin clearance may play a role behind high insulin requirement [3], though mechanism also unknown.…”