1. Acute Diabetes Case B By: Abdullah Osman Christine Tanzil Ayse Togac

2. Jack (51 years) was admitted to hospital with a 24 hour history of drowsiness.

3. Medical History Cardiomyopathy with aortic and mitral regurgitation Cardiomyopathy with aortic and mitral regurgitation Hypertension Hypertension Ischaemic heart disease Ischaemic heart disease

4. Medications Frusemide 40mg MANE Frusemide 40mg MANE A loop diuretic indicated for hypertension. A loop diuretic indicated for hypertension. Lisinopril 20mg DAILY Lisinopril 20mg DAILY An angiotensin converting enzyme inhibitor indicated for hypertension. An angiotensin converting enzyme inhibitor indicated for hypertension. Aspirin 100mg DAILY Aspirin 100mg DAILY An anti-platelet drug indicated for secondary prevention in ischaemic heart disease. An anti-platelet drug indicated for secondary prevention in ischaemic heart disease. Glyceryl trinitrate 600mcg SL PRN Glyceryl trinitrate 600mcg SL PRN A nitrate indicated for angina (IHD) A nitrate indicated for angina (IHD)

5. On examination to the hospital he was: Unconscious Hyperventilating Dehydrated BP = 80/40 Pulse = 120

6. Vigorous rehydration, electrolyte replacement and insulin therapy were administered. Urinalysis was positive for glucose but negative for ketone bodies. A diagnosis of NKHC was suspected.

7. What is NKHC? PART 1

8. What is NKHC? Non-ketotic Hyperosmolar Coma Non-ketotic Hyperosmolar Coma A syndrome characterized by hyperglycaemia, extreme dehydration, and hyperosmolar plasma leading to impaired consciousness, sometimes accompanied by seizures. A syndrome characterized by hyperglycaemia, extreme dehydration, and hyperosmolar plasma leading to impaired consciousness, sometimes accompanied by seizures. Non-ketotic hyperosmolar coma (NKHC) is a complication of type II DM and has a mortality rate of over 50%. Non-ketotic hyperosmolar coma (NKHC) is a complication of type II DM and has a mortality rate of over 50%.

9. What are the signs and symptoms? In some patients, an infection, particularly pneumonia or gram-negative sepsis, is an initiating event; but NKHC can also occur when patients with undiagnosed or neglected type II DM receive drugs that impair glucose tolerance (e.g., Glucocorticoids) or increase fluid loss (e.g., diuretics). In some patients, an infection, particularly pneumonia or gram-negative sepsis, is an initiating event; but NKHC can also occur when patients with undiagnosed or neglected type II DM receive drugs that impair glucose tolerance (e.g., Glucocorticoids) or increase fluid loss (e.g., diuretics).

10. Diagnostic features of NKHC The consistent and diagnostic features of NKHC are CNS alterations, extreme hyperglycaemia, dehydration and hyperosmolarity, mild metabolic acidosis without marked hyperketonemia, and pre- existing chronic renal failure The consistent and diagnostic features of NKHC are CNS alterations, extreme hyperglycaemia, dehydration and hyperosmolarity, mild metabolic acidosis without marked hyperketonemia, and pre- existing chronic renal failure

11. Continued….. The state of consciousness at presentation varies from mental cloudiness to coma. The plasma glucose is usually in the range of 55.5 mmol/L. The calculated serum osmolality on admission is about 400 mmol/L, whereas the normal level is around 280mmol/L. The state of consciousness at presentation varies from mental cloudiness to coma. The plasma glucose is usually in the range of 55.5 mmol/L. The calculated serum osmolality on admission is about 400 mmol/L, whereas the normal level is around 280mmol/L. The mean fluid deficit is about 22% of the total body water, or about 10 L, and acute circulatory collapse is a common terminal event in NKHC The mean fluid deficit is about 22% of the total body water, or about 10 L, and acute circulatory collapse is a common terminal event in NKHC

12. Do the results support the diagnosis? PART II

13. JACK’S RESULTS Na143135-145mmol/L K4.43.8-4.9mmol/L Hb18.213-18g/dL Urea323-8mmol/L pH7.357.36-7.44 Glucose653-8mmol/L Amylase29570-400U/L Creatine kinase 285060-300 Osmolality480265-285mmol/L

14. SIGNS OF NON-KETOTIC HYPEROSMOLAR COMA CNS alterations CNS alterations Increased HR Increased HR Dehydration Dehydration Decreased BP Decreased BP Increased temp Increased temp Thirst Thirst

15. DIAGNOSING NKHC BGL >50mmol/L BGL >50mmol/L pH >7.3 pH >7.3 Bicarbonate slightly decreased Bicarbonate slightly decreased Na and K basically normal Na and K basically normal Large increase in BUN Large increase in BUN Serum Osmolality > 320mmol/l Serum Osmolality > 320mmol/l

16. JACK’S RESULTS Unconscious Unconscious Hyperventilating Hyperventilating Dehydrated Dehydrated BP of 80/40 BP of 80/40 Pulse Rate of 120 Pulse Rate of 120 i.e. indicative of NKHC

17. JACK’S RESULTS Jack Normal Range Diagnosis of NKHC Urea323-8mmol/L Large Increase Osmolality480265-285mmol/L Glucose653-8mmol/L pH7.357.36-7.44>7.3 Na143135-145mmol/LNormal K4.43.8-4.9mmol/LNormal

18. What are the other acute presentations of diabetes apart from NKHC? PART III

19. Diabetic Ketoacidosis (DKA) Mainly occurs in type I diabetics. Mainly occurs in type I diabetics. Ketosis is a condition that is characterised by an elevated serum level of ketone bodies. The ketone bodies are generally found in blood, urine and tissues. Ketosis is a condition that is characterised by an elevated serum level of ketone bodies. The ketone bodies are generally found in blood, urine and tissues. Occurs where there are high levels of blood glucose and glucagon levels. Occurs where there are high levels of blood glucose and glucagon levels. high glucagon levels result in an increased production of ketones. high glucagon levels result in an increased production of ketones. Occurs where there are low levels of insulin. Occurs where there are low levels of insulin. Low insulin levels result in increased ketone production. Low insulin levels result in increased ketone production. The patients generally present with impaired consciousness, dehydration, hyperventilation, low pH, hyperkalemia, potassium deficiency, hyperphosphatemia and phosphate depletion and sodium depletion. The patients generally present with impaired consciousness, dehydration, hyperventilation, low pH, hyperkalemia, potassium deficiency, hyperphosphatemia and phosphate depletion and sodium depletion. K+ and Phosphate depletion due to urinary loss K+ and Phosphate depletion due to urinary loss The acidosis is partly compensated by hyperventilation. The acidosis is partly compensated by hyperventilation. Occurs where there are any changes in hormones (adrenaline, cortisol and growth hormone) result in a mobilisation of free fatty acids from adipose tissue and result in an increase in ketone body production in the liver. Occurs where there are any changes in hormones (adrenaline, cortisol and growth hormone) result in a mobilisation of free fatty acids from adipose tissue and result in an increase in ketone body production in the liver.

20. Hypoglycaemic Coma Glucose levels are generally <2.5mmol/L Glucose levels are generally <2.5mmol/L Insulin levels are elevated or normal and therefore there are generally no ketone bodies present. Insulin levels are elevated or normal and therefore there are generally no ketone bodies present. Patients present with symptoms of anxiety, fainting, hunger, sweating and headache. Patients present with symptoms of anxiety, fainting, hunger, sweating and headache. Hypoglycaemia may be caused by fasting or by other medications such as insulin, sulphonylureas, salicylates and alcohol consumption. Hypoglycaemia may be caused by fasting or by other medications such as insulin, sulphonylureas, salicylates and alcohol consumption.

21. Insulinoma There are generally low blood glucose levels. There are generally low blood glucose levels. Male < 55mg/dL Male < 55mg/dL Female <35mg/dL Female <35mg/dL There are generally elevated insulin levels. There are generally elevated insulin levels. Therefore generally there are no ketone bodies present. Therefore generally there are no ketone bodies present. Diagnosis is confirmed by an elevated plasma insulin levels of >15mU/L and proinsulin levels of >40fmol/L. Diagnosis is confirmed by an elevated plasma insulin levels of >15mU/L and proinsulin levels of >40fmol/L. Levels of insulin may be mimicked by too much use of oral sulfonylurea's or insulin use. Levels of insulin may be mimicked by too much use of oral sulfonylurea's or insulin use.