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A DKA Patient Requiring High Insulin Despite Adequate Fluid Management and IV Insulin Therapy

A 58-year-old lady presented with complaints of vomiting with fever for 4 days and pain abdomen for 2 days prior to admission. Diabetic Ketoacidosis. Her past medical history was significant for hypothyroidism for 8 years, hypertension for 10 years, type diabetes mellitus for 17 years (she says her diabetes started after an abdominal tumor removal- details of which is not available) . 

On general examination, she was conscious, alert and oriented. Her blood pressure was 120/80 mmHg, Pulse was 120/min, temperature was 99.5 degree F. Respiratory system examination showed normal vasicular breath sounds. On cardiac examination, S1 and S2 was audible with no murmur. Abdomen was soft and nontender. CNS examination found no neurological deficits. Her Urine report was positive for ketone body (++). Patient was diagnosed to have diabeteic ketoacidosis. {Her discharge summary and advice on discharge documents are attached below]:




Despite adequate fluid management her glucose levels even on day 5 of treatment remained around 350-400 with Insulin requirements above 350 IU per day. She had no history of intake of steroids in the recent past (though she had taken NSAIDs for few days). Despite detailed evaluation we could not locate any source of infection. She was having constant pruritis and we treated her with antihistaminics and also administered anti scabies medications after taking a Dermatology referral (after Insulin requirements came down). She was obese as per South Asian stds (BMI around 28) with waist circumference of around 105 cm. At this point we introduced Pioglitazone 7.5 mg to the Rx regimen and by day 7 the Insulin requirements came down to abt 60 IU per day. The doubts and queries.


1. Is there any reported case of such high Insulin requirement in DKA patients on Day 5 of Rx despite adequate fluid management and IV Insulin therapy?
2. Did we encounter a case of severe glucotoxicity or severe transient insulin resistance?
3. As we are planning to do a Fasting and Stimulated C Peptide on follow up , do we need to do any further work up( limitations of the setting are there)?

While discussing about this patient, she came to our office for follow-up and her reports are attached below:


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