Undiagnosed type 2 diabetes presenting as diabetic ketoacidosis with hypertriglyceridemia-induced acute pancreatitis

A 27-year-old man presented to the emergency department with 24 hours of generalized abdominal pain, vomiting, polyuria, and lethargy.His medical history included depression (treated with citalopram) and obesity (body mass index 40).He reported minimal alcohol consumption of 0 to 4 units/week, and a family history of type 2 diabetes.He was alert, with a heart rate of 131 beats/min, a respiration rate of 20 breaths/min, oxygen saturation of 96% on room air, a temperature of 37°C, and blood pressure of 169/98 mm Hg.Laboratory investigations revealed a serum sodium level of 128 (reference 133 to 145) mmol/L, a random plasma glucose level of 22.6 (reference < 11.1) mmol/L, and an amylase level of 309 (reference 30 to 118) U/L; serum lipase was not measured.The serum sample was noted to be lipemic by the laboratory staff, who independently performed lipid testing; however, this additional observation was not reviewed by the clinical team during the admission.Venous blood gas analysis showed metabolic acidosis with a pH of 7.24 (reference 7.32 to 7.43) and a bicarbonate level of 11 (reference 22 to 29) mmol/L.Blood and urine dipstick tests were strongly positive for ketones.Abdominal computed tomography (CT) showed features of acute pancreatitis without evidence of biliary disease (Figure 1).Abdominal ultrasonography confirmed a normal biliary tree with no gallstones.The emergency department team diagnosed diabetic ketoacidosis (DKA) associated with acute pancreatitis.On admission to the medical ward, the patient received intravenous fluids, an insulin infusion, intravenous amoxicillin and metronidazole for coverage against intra-abdominal sepsis, and supportive care.His blood glucose control improved, and his symptoms and laboratory abnormalities from acute pancreatitis resolved within a week.He was reviewed by the inpatient diabetes team; they noted a glycated hemoglobin (HbA 1c ) level of 116 mmol/mol (12.8%) and sent samples for diabetes-specific autoantibody tests.He was discharged on insulin therapy with referrals to the outpatient diabetes and gastroenterology clinics.Results from autoantibody tests, reviewed 3 weeks after discharge, were negative for islet antigen-2, zinc transporter 8, and islet cell antibodies.Testing for glutamic acid decarboxylase antibodies could not be performed on the initial sample because Practice | Cases Undiagnosed type 2 diabetes presenting as diabetic ketoacidosis with hypertriglyceridemiainduced acute pancreatitis