Unravelling the increasing complexity of metabolic syndrome: a case of missed diagnostic insights. a rare case presentation of undiagnosed type 2 diabetes mellitus presenting as diabetic ketoacidosis with hypertriglyceridaemia-induced acute pancreatitis
Introduction: Diabetic ketoacidosis (DKA) as an initial presentation in undiagnosed type 2 diabetes mellitus (T2DM) is rare.1 When simultaneously complicated by severe hypertriglyceridaemia (HTG), acute pancreatitis and morbid obesity, this rare metabolic tetrad is potentially life-threatening, with...
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| Main Authors: | , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-07-01
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| Series: | Clinical Medicine |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S1470211825001976 |
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| Summary: | Introduction: Diabetic ketoacidosis (DKA) as an initial presentation in undiagnosed type 2 diabetes mellitus (T2DM) is rare.1 When simultaneously complicated by severe hypertriglyceridaemia (HTG), acute pancreatitis and morbid obesity, this rare metabolic tetrad is potentially life-threatening, with increased mortality and morbidity,2–8 because each condition worsens the other.7 Risk of developing pancreatitis increases with triglyceride (TG) levels more than 11.3 mmol/L and increases by 3% for every 100 mg/dL rise.5,9 Nevertheless, TG levels often go unmeasured in most pancreatitis patients (70%).10 This case report highlights the increasing complexity of presentation of metabolic diseases in today’s world. Case presentation: A 27-year-old man with obesity (body mass index (BMI) 40 kg/m2) presented with abdominal pain, vomiting, polyuria and lethargy. Past medical history included asthma and depression treated with citalopram. Family and social history was unremarkable. Results showed hyperglycaemia (22.6 mmol/L), metabolic acidosis (pH 7.24), raised amylase levels (309 U/L) and HbA1c (116 mmol/mol) (Table 1). Abdominal imaging confirmed acute pancreatitis without gallstones. He was diagnosed with DKA and pancreatitis. Treatment included intravenous fluids, insulin infusion, antibiotics and supportive care. Clinical improvement was seen within a week and he was discharged on insulin therapy. Given his age at diagnosis and presentation with DKA, type 1 diabetes mellitus was suspected.During a follow-up visit, the classification was revised when the diabetes auto-antibodies (GAD, IA2 and ZnT8) came back negative and there was the presence of insulin resistance. During the clinic review, it was noted that the patient had severe hypertriglyceridaemia (TG 41.5 mmol/L) at initial hospital presentation with DKA. A diagnosis of hypertriglyceridaemia-induced pancreatitis was made retrospecitvely in the diabetes clinic and repeat TG showed persistent severe hypertriglyceridaemia levels of 15.0 mmol/L, suggesting increased risk of further potentially fatal pancreatitis. Discussion: This case illustrates critical diagnostic and management oversights in a complex metabolic emergency, such as failure to diagnose the primary aetiology of pancreatitis even with history of insignificant alcohol intake and absence of gallstones. This oversight resulted in a missed opportunity to manage critical hypertriglyceridaemia. The use of insulin infusion to treat DKA would have helped to reduce TG levels by activating lipoprotein lipase. However, appropriate treatment protocols should have included more aggressive insulin therapy targeting TG reduction, consideration of plasmapheresis, early initiation of lipid modifying therapies and specific dietary interventions. Hypertriglyceridaemia was identified as an issue during a diabetes clinic visit 6 months after hospitalisation. This left the patient at high risk of recurrent pancreatitis without specific dietary fat restriction, TG monitoring, timely initiation of lipid-lowering therapy and specialist referrals. Conclusion: This case presents an individual fortunate enough to avoid life-threatening complications of severe hypertriglyceridaemia and shows the increasingly complex pathophysiology of diabetes presentation in younger adults as a result of the rising epidemic of obesity. A systematic, multidisciplinary approach is crucial to enhance recognition of these interconnected conditions with routine TG measurement in all acute pancreatitis cases, aggressive management during hospitalisation, comprehensive discharge planning, regular monitoring and appropriate specialist referrals. |
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| ISSN: | 1470-2118 |