Case presentation: A 17 month old female child was transferred to our hospital from another hospital where she was admitted to the intensive care unit (ICU) due to cerebral edema, diabetic acidosis and severe dehydration. The patient had fever, polyuria, polydipsia and vomiting presented four days before admission. At her admission she was unconscious with dilated pupils, no reaction to painful stimuli (GCS 4/15) and Kussmaul breathing. Her initial blood glucose level was 391 mg/dl, pH 6.85, HC03=5 mmo/l, lactic Acid=1.8 and urine test ketones+. Her personal history was unremarkable with no vaccinations and exclusively vegan diet. She remained at the ICU 18 days, where she developed renal failure (urea 104 mg/dl, creatinine 2.86 mg/dl, creatinine clearance 2.6 ml/min per 1.73 m2, urine albumin 93 mg/24 h), hypoalbuminemia (albumin=2.7 mg/dl), hypokalemia, thrombosis of right femoral artery, anemia (Hb 8.713.7 g/dl, required 7 blood transfusions), thrombocytopenia, hypertransaminasemia-hyperamylasemia (SGOT 480 mg/dl, 171 mg/dl, amylase 629 U/l), febrile infection and extended skin edema with epidermal necrosis. Plasma lipids levels were: total cholesterol=67 mg/dl, triglycerides=329 mg/dl. Her initial HbA1c=9,4%. When she was admitted to our hospital she was afebrile, without metabolic acidosis with extended exfoliation of the skin. Laboratory tests were: Glucose 53 mg/dl, urea=20 mg/dl, creatinine=0.4 mg/dl, K=4.5 mmol/l, Na=139 mmol/l, amylase 32 U/L, lipase 56 U/l, total cholesterol=108 mg/dl, HDL=47 mg/dl, LDL=41 mg/dl, TGL=135 mg/dl, TSH 23.49 mIU/ml, HbA1C=5.8% (last blood transfusion 6 days before admission to our hospital), C-peptide <0.1 ng/ml, ICA and ZnT8 antibodies (−). She was treated with multiple dose insulin injections and her general condition improved.
Discussion: We present an unusual case of severe diabetic acidosis with mild ketosis and normal lactic acid in an exclusively vegan diet child. This could be possible due to the effects of vegetarian diets on low blood lipid concentrations. Differential diagnosis includes the case of fulminant diabetes due to acute-onset of diabetes clinical symptoms, low c-peptide, negative auto-antibodies and increased pancreatic enzyme levels, according to the international diagnostic criteria.
Conclusion: Diabetes is considered a rather heterogeneous disease. This case does not fit into the existing concepts of either fulminant or idiopathic type 1a diabetes, thereby further highlighting the heterogeneity of diabetes. The vegan diet may possible affect the presentation of the disease, therefore the influence on vegan diet in the disease presentation needs further investigation.
27 - 29 Sep 2018
European Society for Paediatric Endocrinology