Diabetic Ketoacidosis With Hypertriglyceridemia-Induced Acute Pancreatitis As First Presentation Of Diabetes Mellitus: Report Of Three Cases

ABSTRACT Objective:We present a series of three cases of hypertriglyceridemia-induced acute pancreatitis with concurrent diabetic ketoacidosis (DKA) as first presentation of type 2 diabetes mellitus in adult patients. This triad has been described in previous literature; however, it is extremely rare in previously undiagnosed diabetic patients. We discuss the potential mechanism, diagnosis, management strategies, and prognosis in these cases. Methods:Three patients with no known history of diabetes mellitus or hyperlipidemia presented with diabetic ketoacidosis, elevated serum triglycerides, and typical symptoms of acute pancreatitis. Diagnosis was confirmed with abdominal computed tomography (CT) scan, and all three patients were managed in intensive care units, received aggressive fluid repletion, intravenous insulin, and lipid-lowering agents. Results:Two patients had uneventful recovery with rapid resolving hyperglycemia and hypertriglyceridemia. One patient had severe complication of acute kidney injury, sepsis, and acute respiratory distress syndrome, requiring temporary continuous veno-veno hemodialysis, antibiotic treatment, and transient intubation. All patients were discharged on subcutaneous insulin and lipid-lowering agents. They remained symptom-free during follow-ups. Conclusion: The triad of DKA with concurrent hypertriglyceridemia-induced acute pancreatitis occurs in approximately 4% of DKA cases. However, it is extremely rare as first presentation of diabetes in adult patients. A prompt diagnosis is challenging, although crucial for appropriate management. CT scan and lipid panel should be performed to confirm diagnosis when there is clinical suspicion or no improvement after treatment of DKA. Management mainly consist of intravenous fluids, continuous insulin infusion, and lipid-lowering agents. Plasmapheresis with success has been reported in previous literature; however, it was not necessary in our cases. Abbreviations: ABG arterial blood gas AP acute pancreatitis CT computed tomography DKA diabetic ketoacidosis