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Transient extreme insulin resistance in childhood onset diabetes mellitus type 1 presenting with severe diabetic ketoacidosis, hyperlipidemia and acute pancreatitis

Background: Mild increase in serum lipid concentrations is a common feature of diabetic ketoacidosis (DKA) while severe hyperlipidemia (HL) with milky plasma is rare. HL is an uncommon cause of acute pancreatitis (AP), especially in children. The risk for developing AP rises when serum triglyceride level exceeds 11 mmol/L (1.000 mg/dL). Some extent of insulin resistance (IR) is present in almost all cases of DKA while severe IR is exceedingly rare. Case report: We report on a 5-year-old, previously healthy, nonobese girl with newly diagnosed diabetes mellltus type 1 who presented with distended abdomen, severe abdominal pain, hypovolemic shock and altered mental status. Laboratory examination revealed DKA. As well, her serum was milky showing severe HL (triglycerides: 241.97 mmol/l ; ref. < 1.7 mmol/l and total cholesterol 40.1 mmol/L ; ref. < 5.0 mmol/l), while the CT scan showed signs of AP. In spite of insulin and fluid therapy introduced according to ISPAD DKA protocol, blood glucose levels remained high with prolonged metabolic acidosis until extremely high doses of insulin were administered (up to 1.1 IU/kg/h). Due to severe HL and AP two courses of plasmapheresis were performed with consequent decrease in triglyceride and lipase levels. However, we also noticed restituition of insulin sensitivity, reverse of acidosis and clinical improvement. Conclusion: To the best of our knowledge this is the first report of co-existence of DKA, HL and AP accompanied with extreme IR in pediatric patient. Plasmapheresis was shown to be an effective treatment for severe hyperlipidemic pancreatitis in a child with DKA. Nevertheless, we also observed recovery

diabetic ketoacidosis, insulin resistance, hyperlipidemia, pancreatitis

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