ESPE Abstracts (2014) 82 P-D-3-3-757

Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema: Complications of Severe DKA in T2DM Obese Patient

Federica Ortolania, Albina Tummoloc, Cataldo Torellia, Maristella Masciopintoa, Stefania Fedelea, Francesco Nicastroa, Francesco Papadiaa, Marcella Vendemialeb & Elvira Piccinnoa

aMetabolic Diseases, Clinical Genetics and Diabetology, Pediatric Hospital Giovanni XXIII, Bari, Italy; bClinical Psychology, Pediatric Hospital ‘Giovanni XXIII’, Bari, Italy; cUOC Hereditary Metabolic Diseases, Azienda Ospedaliera Policlinico di Padova, Padova, Italy

Case presentation: G. 15 years 8 months; H 180 cm; P 149.6 kg, BMI 46 kg/m2, second born, father obese, healthy mother and two brothers, no familiarity for T1DM/T2DM, no gestational diabetes. Bronchial asthma, since 2-year-old important weight increase. Flue, polyuria, polydipsia, 12 kg loss in 15 days, anorexia since 5 days, vomit. Hospitalized for tachycardia, dyspnea, and asthenia. On arrival: serious dehydration, Kussmaul breathing, neck subcutaneous emphysema, tachycardia 130/min, A.P. 125/70 mmHg.

Diagnostic procedures, therapy, and follow up: Glycemia 663 mg/dl, ketonemia 4.8 mmol/l, anion gap 24 mEq/l, K 2.5 mEq/l, HbA1c 11.4%, GOT 77 UI/l, GPT 73 UI/l, amilase 204 U/l, lipase 723 U/l, colesterol 250 mg/dl, tryglicerides 301 mg/dl, C-peptide 0.37 ng/ml, negative IAA, GAD and IA2. Chest CT scan: large anterior pneumomediastinum, left apical pneumothorax, neck subcutaneous emphysema. Abdomen ultrasound: steatosic enlarged liver. I.v. therapy on arrival: physiologic saline solution, potassium, 15 fl of sodium bicarbonate, subcutaneous rapid insulin 20 U. 12 h later transferred to our department, metabolic–hydroelectrolytic correction for DKA with i.v. insulin 12–18 U/h. Equilibrium in 48 h, potassium normalisation in 4 days, amilase and lipase in 1 week. Seven days later, insulin pump implantation (total insulin: 5 U/h+three bolus), started therapy with metformin (1500 mg/day). Dismissed with insulin pump (basal+two bolus), after 1 month infused only low basal insulin, suspended after 6 months (pre-prandial C-peptide 3.5 ng/ml and HbA1c 5.3%). Metformin suspended after 16 months (weight 90 kg, BMI 27.8%, and HbA1c 5.1%), 30 months later normal OGTT and insulinemia, C-peptide 2.7 ng/ml, and HbA1c 4.9%.

Considerations: The severe outset might have suggested T1DM diagnosis (negative family history for T2DM). Importance of insulin pump therapy for preserving pancreatic β cells activity. Hypocaloric diet and adequate lifestyle determined weight loss and the patient did not require any therapy: total remission or healing?