European Journal of Cardiovascular Medicine

Diabetic ketoacidosis (DKA) is a medical emergency frequently seen in Type 1 Diabetes Mellitus (T1DM), characterized by hyperglycemia, metabolic acidosis, ketonemia and dehydration. Common precipitating factors include infections, acute stress and insulin non-compliance. Acute pancreatitis is one of the uncommon triggers of DKA and, when present, is often associated with hypertriglyceridemia [1]. Hypertriglyceridemia-induced pancreatitis (HTGP) represents a diagnostic challenge and contributes to increased morbidity and mortality in patients with DKA [2].

This case report presents a rare and life-threatening manifestation of undiagnosed T1DM in a young adult, presenting with DKA, HTGP, AKI, and ARDS. Prompt and coordinated care in the intensive care setting led to a full recovery without surgical intervention.

A 23-year-old previously healthy male presented to the emergency department on 15/03/2025 with a two-week history of abdominal pain, worsening over 24 hours, and associated with gasping respiration. On examination, he was unresponsive with a GCS of E2V1M3.

Initial Vitals:

• Pulse: 120 bpm
• Blood Pressure: Unrecordable
• Temperature: 98°F
• SpO2: 96% on room air
• Capillary Blood Glucose: 428 mg/dL
• Respiratory rate: 35 / min
• Breathing pattern: deep, rapid and laboured

Physical Exam: Soft-to-firm abdomen with intestinal peristalsis present, severe dehydration.

Provisional Diagnosis: Diabetic ketoacidosis with shock and altered mental status.

ICU MANAGEMENT AND INVESTIGATIONS

He was immediately intubated and transferred to the ICU. Management included:

• Vasopressors (noradrenaline and vasopressin)
• IV fluids and bicarbonate correction
• Insulin infusion (Human Actrapid)
• Electrolyte replacement
• Antibiotics, PPIs, antiemetics, and nasogastric decompression

Investigations:

• ABG: High anion gap metabolic acidosis
• Urine: Ketone bodies ++
• Serum biochemistry:
• Triglycerides: 730 mg/dL
• Lipase: 1124 U/L
• Amylase: 658 U/L
• Creatinine: Rising from 0.9 to 4.6 mg/dL
• HbA1C: 14.2%
• Calcium: 7.2 mg/dL
• Potassium: 3.1
• PCT: 26.74 ng/mL
• CBC: Hb 9.3 g/dL, WBC 12,900/mm³, Platelets 1.25 lakh/mm³
• Ultrasound: Acute pancreatitis, bilateral renal parenchymal disease, fatty liver, interloop ascites

CLINICAL COURSE

Initially diagnosed with DKA precipitated by hypertriglyceridemia-induced pancreatitis and shock, the patient showed minimal urine output (anuria) and progressive AKI. He was planned for dialysis due to worsening renal function.

On Day 2, he regained consciousness (GCS E4V4M5) and was extubated. However, on Day 3, he developed acute respiratory distress syndrome (ARDS), likely due to systemic inflammation from pancreatitis and fluid shifts. He was managed with:

• Non-invasive ventilation
• Conservative fluid strategy
• Close hemodynamic monitoring

Over the next few days, the patient made a remarkable recovery:

• AKI improved with conservative management and supportive therapy (dialysis was ultimately discontinued).
• Inflammatory markers normalized.
• Chest X-ray showed resolution of pulmonary infiltrates.
• Abdominal symptoms gradually resolved.

Enteral feeding was initiated gradually. After full clinical stabilization, he was discharged in stable condition with basal bolus insulin regime.

Prior to discharge, he and his family members were counselled extensively on:

• The diagnosis of Type 1 Diabetes Mellitus
• The need for lifelong insulin therapy & CBG monitoring
• The importance of strict adherence to insulin dosage and follow-up
• Recognition of symptoms of DKA and sick-day rules

During hospital stay he was under joint care by an internal medicine specialist, a general surgeon, a nephrologist, a gastroenterologist and intensivist.

This case highlights a complex and rare interplay of hypertriglyceridemia, pancreatitis, and DKA in a patient with previously undiagnosed T1DM. Hypertriglyceridemia may act as both a consequence of insulin deficiency and a direct trigger of acute pancreatitis, especially when levels exceed 500–1000 mg/dL [3].

DKA itself promotes lipolysis and ketogenesis, which exacerbates hypertriglyceridemia, creating a vicious cycle. Pancreatitis can further complicate fluid management due to third-space losses and may precipitate ARDS and AKI, as seen in this case.

The patient’s successful recovery was likely due to early recognition, intensive supportive care, and a multidisciplinary approach. This case reinforces the importance of:

• Considering pancreatitis in patients with DKA and abdominal pain
• Checking lipid profiles in unexplained or severe DKA cases
• Prompt critical care involvement in multi-organ dysfunction

This case underscores the importance of early identification and aggressive management in patients presenting with DKA and severe metabolic complications. Hypertriglyceridemia-induced pancreatitis, although rare, should be considered in newly diagnosed diabetics with abdominal pain. With timely intervention, even critically ill patients with multi-organ dysfunction including AKI and ARDS can achieve full recovery.

Patient Perspective

The patient expressed relief at recovering from such a life-threatening illness and was grateful for the intensive support provided. He acknowledged the importance of adhering to his new insulin regimen and committed to regular follow-ups and self-monitoring to manage his condition effectively.

1. Kitabchi AE, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Diabetes Spectrum. 2009.
2. Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterol. 2003.
3. Anderson F, et al. Hypertriglyceridemia-induced pancreatitis as a rare cause of DKA. Case Rep Endocrinol. 2020.
4. Yuan G, et al. Hypertriglyceridemia and pancreatitis. Am J Physiol Endocrinol Metab. 2012.

5. Muniraj T, et al. Acute pancreatitis. Dis Mon. 2015.