ESPE Abstracts

Introduction: DKA is one of the most common pediatric emergencies. Hypertriglyceridemia and acute pancreatitis are infrequent complications of DKA. We present a 9-year-old female with new-onset DKA who presented with acute pancreatitis and hypertriglyceridemia and resolved on follow-up.

Case presentation: A 9-year-old female, previously healthy, non-obese, presented to the hospital with breathing difficulty, abdominal pain, and reduced oral intake. She had a history of polyuria, polydipsia, and weight loss for two months. She was found to have DKA (serum glucose 499 mg/dL, urine glucose > 1000 mg/dL, urine ketone 3+, capillary blood pH of 6.85, serum bicarbonate undetectable). She was in compensated shock and severe dehydration, so she received two IV boluses (10 ml/kg) of crystalloid fluid. She was admitted to PICU and started on DKA management protocol with IV insulin and IV fluids. Her examination revealed Kussmaul's breathing, altered mental status, and signs of poor perfusion (tachycardia 140/min, capillary refill time 3-4 seconds, bilateral weak peripheral pulses). Her blood samples were "too thick and milky." Her initial serum triglyceride (TG) level was 988 mg/dL (11.16mmol/l) and total cholesterol 115 mg/dL. Abdominal ultrasound was consistent with acute pancreatitis and ruled out other pathologies. Her mental status gradually improved after 6-8 hours, along with the stabilization of serum glucose. Initial serum amylase was 239U/L (28 – 100), and lipase was 1982 U/L (13 – 60). After 12-36 hours, her appetite improved with a downward trend of serum TG 604 mg/dL (6.8mmol/l), serum lipase (273 U/L), and serum amylase 173 U/L. After 48 hours, she started on oral feeds and subcutaneous insulin. Two weeks after discharge, her TG level normalized to 127mg/dL (1.44mmol/l).

Discussion: Hyperlipidemia and acute pancreatitis are rare complications of DKA. Insulin deficiency in DKA causes hypertriglyceridemia by decreasing lipoprotein lipase activity, which converts triglycerides to fatty acids. The triad of DKA, hypertriglyceridemia, and acute pancreatitis have been well described in adult literature but rarely in the pediatric population.

Conclusions: In DKA, clinically significant acute pancreatitis can be attributed to severe hypertriglyceridemia if the serum TG level is > 1000 mg/dL (11.3mmol/l). Lipemic blood can be the clue to hypertriglyceridemia as a cause of acute pancreatitis and the resultant worsening of DKA despite standard insulin therapy. Early recognition has important implications in the management as insulin requirements and the tempo of recovery can be altered.