Is diabetes mellitus complicated by ketoacidosis in the elderly always latent autoimmune diabetes of the adult?

doi:10.15406/jdmdc.2016.03.00073

Journal of

eISSN: 2374-6947

Diabetes, Metabolic Disorders & Control

Case Report Volume 3 Issue 4

Is diabetes mellitus complicated by ketoacidosis in the elderly always latent autoimmune diabetes of the adult?

Bahar Ozdemir,¹ Betul Erismis,¹ Hakan Kocoglu,¹ Yıldız Okuturlar,¹ Didem Acarer,¹ Tarık Ercan,¹ Mehmet Hursitoglu,¹ Ozlem Harmankaya,¹ Meral Mert²

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¹İnternal Medicine, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Turkey
²Endocrinology, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Turkey

Correspondence: Meral Mert, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, Tel +902 124 147 171

Received: June 10, 2016 | Published: July 6, 2016

Citation: Ozdemir B, Erismis B, Kocoglu H, et al. Is diabetes mellitus complicated by ketoacidosis in the elderly always latent autoimmune diabetes of the adult? J Diabetes Metab Disord Control. 2016;3(4):74-75. DOI: 10.15406/jdmdc.2016.03.00073

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Introduction

Diabetic Ketoacidosis (DKA) which is seen usually in Type 1, latent autoimmune diabetes of the adult (LADA) and rarely in Type 2 Diabetes Mellitus (DM) is a acute complication.^1,2 It is the cause of 50% of hospital admissions due to diabetes in young patients and also 1-2% of all diabetic hospital admissions. According to United States database, the annual incidence of DKA is 4.6-8 episodes per 1000 diabetic patients. The mortality rate in developed countries is reported to be between 2-10%. There is 20% mortality over 65 years age.

Case 1

66-year-old female patient was admitted with confused concious and impaired orientation. Vital signs in the initial evaluation of the patient were as follows. TA: 100/70 mm Hg, respiratory rate 28/min, heart rate 124 /min, fever 38.4C. Upon admission, blood glucose was determined as 651mg/dl in the emergency department. Arterial blood gas analysis was consistent with metabolic acidosis with increased anion gap. The patient’s urine analysis was evaluated as ketone positive. She was diagnosed as pneumosepsis (confirmed by physical examination, blood and sputum cultures) and diabetic ketoacidosis. The patient was treated with diabetic ketoacidosis treatment protocol. The patient had history of hypertension, but no history of DM in either herself or her family. Her height, weight, BMI were 160 cm, 75 kg, BMI 29.3 kg / m2 , respectively. The patient’s HbA1c was determined as 10.5%. C-peptide level of the patient was lower than normal (1.8 ng / ml), the antibody was negative. Treatment was regulated with diet and frequent intermittent subcutaneous insulin therapy. She was considered to be diabetic ketoacidosis diagnosed firstly as hyperglycemic crisis.^3-5

Case 2

80-year-old male patient was admitted to our emergency department with confused conscious. The patient’s vital signs were stable. The blood glucose level was measured as 718 mg/dL, urinalysis was ketone positive,arterial blood gas analysis was as follows : pH 7.01, pCO2 20.4 mmHg, HCO 3: 5 mmol / L, Na: 137 mmol/L, Cl: 107 mmol / L. The patient was treated as diabetic ketoacidosis and urinary tract infection. He had HbA1c level of 10.4%, C-peptide <12:10 ng / ml, islet cell antibody positive (1:32), anti GAD> 2000 IU / ml (<10), insulin antibody 40.62% positive. The patient who were diagnosed at 65 years age and followed for 15 years was hospitalized to the clinic with diabetic ketoacidosis. He was evaluated as LADA due to the positive antibodies.

Discussion

DKA can be seen in the elderly, whether autoimmune DM or not. Along with insulin deficiency, elevated catecholamine activates cortisol and growth hormone sensitive lipase and causes the destruction of triglycerides and the release of free fatty acids. They are used for making ketone bodies, beta-hydroxy butyric acid and acetoacetic acid. Acetoacetate is converted to acetone with non-enzymatic decarboxylation and ketone bodies produced are partly excreted in urine. At physiological pH, ketoacids are separated and increased hydrogen ions reduce serum bicarbonate levels by connecting bicarbonate. Ketone bodies with in the form of anions in circulation increase anion gap. Metabolic acidosis with increased anion gap occurs with reduced bicarbonate level. The mortality rate increases with age in DKA, while the rate is 10% under 75 years of age, 19% between 79-84 years of age and reaches 35% over 85 years. There is no difference in DKA treatment according to age. It is an acute complication of diabetes regardless of age. Autoimmune diabetes should be kept in mind in the differential diagnosis, while assessing each patient.