413- A 16-year-old boy who is a known patient of T1DM presented with altered sen-
sorium. On examination, he had mild dehydration and BP was 110/70 mmHg.
His blood glucose was 280 mg/dl, arterial pH 7.28, bicarbonate 12 mEq/L, and
urine ketone 3+. Serum sodium was 132 mEq/L, potassium 4 mEq/L, and urea
40 mg/dl. How to proceed further?
The index patient presented with DKA and altered sensorium. Patients with
DKA usually do not present with altered sensorium unless accompanied with
marked dehydration, dyselectrolytemia, or severe acidosis. DKA-related altered
sensorium is usually associated with hyperosmolality (serum osmolality
>320 mOsm/Kg), which results in marked cerebral intracellular dehydration. In
the index case, calculated serum osmolality was 295 mOsm/Kg; there was no
electrolyte abnormality and acidosis was mild. Therefore, alternative causes for
altered sensorium should be actively sought in the index patient including men-
ingitis, cortical vein thrombosis, stroke, and rhinocerebral mucormycosis. In
addition, rapid reduction in blood glucose can also lead to altered sensorium in
a patient recovering from DKA due to cerebral edema as a result of osmotic
disequilibrium. The index patient was evaluated and was found to have concur-
rent pyogenic meningitis.- How do SGLT2 inhibitors induce DKA?
Few cases of euglycemic DKA have been reported with the use of SGLT2
inhibitors in patients with both T1DM and T2DM particularly during stress.
Decrease in blood glucose due to glucosuria as a result of SGLT2 inhibitors use
led to deceptive decrease in insulin doses and consequent development of DKA
in these patients during the period of stress (a state of heightened insulin resis-
tance). This is because of relatively lower portal concentration of insulin is
required to suppress hepatic glucose output (fasting hyperglycemia) as com-
pared to inhibition of ketosis. In addition, hyperglucagonemia associated with
the use of SGLT2 inhibitors also favors ketogenesis. Further, hypovolemia due
to water and Na+ loss resulting from SGLT2 inhibition lead to increased coun-
terregulatory hormones secretion (cortisol and epinephrine), and consequent
increased lipolysis and ketogenesis.- What are the infections specific to diabetes?
Patients with diabetes are predisposed for certain infections which include
emphysematous pyelonephritis, emphysematous cholecystitis, malignant otitis
externa, rhino–orbito–cerebral mucormycosis, and liver abscess. The increased
risk for these infections in patient with diabetes is due to glucotoxicity- mediated
lazy leukocyte syndrome and impaired humoral and cellular immunity
(Fig. 12.3).12 Diabetes in the Young