Very Severe Hypertriglyceridemia in Children with Diabetic Ketoacidosis
Abstract
Background: Hypertriglyceridemia can be observed in up to 50% of patients with diabetic ketoacidosis (DKA), but a condition for DKA with very severe hypertriglyceridemia is uncommon. The objective of this case report is to present and describe the clinical features, laboratory investigations, case management, and natural course of hypertriglyceridemia in DKA
Case summary: A 9-year-old girl referred by district hospital with DKA and hypertriglyceridemia. Chief complaint was a decreased in consciousness for 16 hours before the admission. Patient has been known to suffer from diabetes mellitus within these 9 months. At ER patient looked severely ill, GCS 7, Kussmaul breathing. Random blood glucose was 255 mg/dL. Glycosuria and ketone urine tests were positive. Triglyceride level was 16.200 mg/dL. She had diagnosed with diabetic encephalopathy, DKA and very severe hypertriglyceridemia due to DKA. We treat DKA with standard guidelines, and on the 15th day we gave additional therapy fibrates and omega oil to treat the very severe hypertriglyceridemia. The level of triglyceride decreased gradually with hydration and insulin in standard guideline for DKA but didn’t achieve the normal level. With additional treatment, normal level of triglyceride achieved without any clinical side effects.
Conclusion: Triglyceride level should be monitored in DKA patients. The hypertriglyceridemia can be treated by hydration, insulin, fibrates, and omega oil. The use of these treatment need to be evaluated for side effects.
Keywords
References
Valaiyapathi B, Sunil B, Ashraf AP. Approach to hypertriglyceridemia in the Pediatric Population. Pediatr Rev. 2017;38:424-34.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213–56.
Shah AS, Wilson DP. Primary hypertriglyceridemia in children and adolescents. J Clin Lipidol. 2015;9:S20-8.
Zaher FZ, Boubagura I, Rafi S, Elmghari G, Elansari N. Diabetic ketoacidosis revealing a severe hypertriglyceridemia and acute pancreatitis in type 1 diabetes mellitus. Case Rep Endocrinol. 2019;2019:1-4.
Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. 2018;19:155-77.
Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001;344:264-9.
Valaiyapathi B, Ashraf AP. Hospital management of severe hypertriglyceridemia in children. Curr Pediatr Rev. 2018;13:225-31.
Fulop M, Eder H. Severe hypertriglyceridemia in diabetic ketosis. Am J Med Sci. 1990;300:361-5.
Lutfi R, Huang J, Wong HR. Plasmapheresis to treat hypertriglyceridemia in a child with diabetic ketoacidosis and pancreatitis. Pediatrics. 2012;129(1):195-8
Shah AS, Wilson DP. Genetic Disorders Causing Hypertriglyceridemia in Children and Adolescents. South Dartmouth (MA): MDText.com, Inc.;2000-.
Mărginean CO, Meliţ LE, Dobreanu M, Mărginean MO. Type V hypertriglyceridemia in children, a therapeutic challenge in pediatrics. Medicine (Baltimore). 2017;96:e8864.
Quintanilla RBS, Correa R. Gemfibrozil. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2020:Jan-.
Skulas-Ray AC, Wilson PWF, Harris WS, Brinton EA, Kris-Etherton PM, Richter CK, et al. Omega-3 fatty acids for the management of hypertriglyceridemia: ascience advisory from the American Heart Association. Circulation. 2019;140:e673-91.
Del-Rió-Navarro BE, Miranda-Lora AL, Huang F, Hall-Mondragon MS, Leija-Martínez JJ. Effect of supplementation with omega-3 fatty acids on hypertriglyceridemia in pediatric patients with obesity. J Pediatr Endocrinol Metab. 2019;32:811-9.
Chahal N, Manlhiot C, Wong H, McCrindle BW. Effectiveness of omega-3 polysaturated fatty acids (fish oil) supplementation for treating hypertriglyceridemia in children and adolescents. Clin Pediatr (Phila). 2014;53:645–51.
Cywinski JS, Walker FA, White H, Traisman HS. Juvenile diabetes mellitus associated with acute pancreatitis. Acta Paediatr Scand. 1965;54:597–602.
Slyper AH, Wyatt DT, Brown CW. Clinical and/or biochemical pancreatitis in diabetic ketoacidosis. J Pediatr Endocrinol.;7:261–4.
Kadota-Shinozaki A, Nakamura TA, Hidaka H, Kojima H, Yasuda H, Kashiwagi A, et al. Diabetic Lipemia with maturity-onset diabetes of the young. Intern Med. 1997;36:571-4.
Fortson MR, Freedman SN, Webster PD. Clinical assessment of hyperlipidemic pancreatitis. Am J Gastroenterol. 1995;90:2134-9.
Lee CY , Lee MK , Lee SY , Hong SN , Kim HH , Kang BH et al. A case of acromegaly with diabetic ketoacidosis and hypertriglyceridemia-induced acute pancreatitis. J Korean Soc Endocrinol. 2002;17(1):110-6
Choi DS , Oh JH , Park IB , Kim JW , Choi KM , Kim YH, et al. A case of severe hypertriglyceridemia with diabetic ketoacidosis, J Korean Diabetes Assoc. 1999;23(5):715-21
Hahn SJ, Park JH, Lee JH, Lee JK, Kim KA. Severe hypertriglyceridemia in diabetic ketoacidosis accompanied by acute pancreatitis: case report. J Korean Med Sci. 2010;25:1375-8.
Kota S, Jammula S, Kota S, Meher L, Modi K. Acute pancreatitis in association with diabetic ketoacidosis in a newly diagnosed type 1 diabetes mellitus patient; case based review. IJCCI. 2012;4:54-60.
Aboulhosn K, Arnason T. Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis. BMJ Case Rep. 2013.
Wolfgram P, MacDonald M. Severe hypertriglyceridemia causing acute pancreatitis in a child with new onset type I diabetes mellitus presenting in ketoacidosis. J Pediatr Intensive Care. 2015;02:077-80.
Saengkaew T, Sahakitrungruang T, Wacharasindhu S, Supornsilchai V. DKA with severe hypertriglyceridemia and cerebral edema in an adolescent boy: acase study and review of the literature. Case Rep Endocrinol.2016;7515721
Sharma PK, Kumar M, Yadav DK. Severe hypertriglyceridemia causing pancreatitis in a child with new-onset type-i diabetes mellitus presenting with diabetic ketoacidosis. Indian J Crit Care Med. 2017;21:176-8.
Richardson T, Aslibekyan S, Ashraf AP. Clinical characteristics and sequelae of severe hypertriglyceridemia in pediatrics. Endocr Pract. 2018;24:789-95.
Abu-El-Haija M, Kumar S, Quiros JA, Balakrishnan K, Barth B, Bitton S, et al. Management of acute pancreatitis in the pediatric population: aclinical report from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. JPGN. 2018;66(1):159-71.
Keefe C, Lawson S. ApoE isoform leading to hypertriglyceridemia in new onset type 1 diabetes. Clin Case Reports. 2018;6:1287-90.
Karagianni C, Stabouli S, Roumeliotou K, Traeger-Synodinos J, Kavazarakis E, Gourgiotis D, et al. Severe hypertriglyceridaemia in diabetic ketoacidosis: clinical and genetic study. Diabet Med. 2004;21:380-2.
Matern D, Seydewitz H, Niederhoff H, Wiebusch H, Brandis M. Dyslipidaemia in a boy with recurrent abdominal pain, hypersalivation and decreased lipoprotein lipase activity. Eur J Pediatr. 1996;155:660-4.
DOI: 10.24815/jks.v21i2.20087
Refbacks
- There are currently no refbacks.