Patient Overview
A 60-year-old male with a history of psoriatic arthritis, alcohol-associated liver cirrhosis, portal hypertension, and esophageal varices presented to the emergency department with a 3-day history of altered mental status. Associated symptoms included malaise, fatigue, decreased appetite, and progressive behavioral changes, including fidgeting movements, mistaking the door for a window, and urinating on the floor.
His home medications included guselkumab 100 mg every 8 weeks, furosemide 40 mg daily, spironolactone 100 mg daily, carvedilol 25 mg twice daily, and lactulose 10 mL daily. Guselkumab had been initiated four months earlier after discontinuation of adalimumab because of recurrent methicillin-sensitive Staphylococcus aureus bacteremia secondary to lower limb cellulitis. He had no prior history of diabetes mellitus or prediabetes. His last glycated hemoglobin (HbA1c), measured five months before presentation, was 5.2%.
Clinical Presentation
On examination, the patient was obtunded and responsive only to painful stimuli, although airway protective reflexes were preserved. Vital signs at admission included temperature 98.8°F, blood pressure 148/98 mmHg, heart rate 98 beats/minute, respiratory rate 22 breaths/minute, and oxygen saturation 98% on room air.
Urgent computed tomography (CT) imaging of the head showed no acute intracranial abnormality. Abdominal ultrasound demonstrated cirrhotic liver morphology with mild ascites that was not amenable to drainage.
Laboratory Findings
Initial laboratory evaluation demonstrated high-anion gap metabolic acidosis with marked hyperglycemia and elevated beta-hydroxybutyrate levels, findings consistent with diabetic ketoacidosis. Glycated hemoglobin (HbA1c) was elevated at 10.2%, compared with 5.2% recorded five months earlier.
Additional biochemical and hematological abnormalities are summarized in Table 1. Further evaluation demonstrated preserved endogenous insulin secretion with normal C-peptide levels and negative anti-insulin and anti-glutamic acid decarboxylase (GAD) antibodies. CT imaging of the abdomen demonstrated cirrhosis with portal hypertension and upper abdominal varices, with no pancreatic abnormality identified.
Table 1. Summary of Laboratory Findings
Tests | Result | Reference Range |
Bicarbonate, mEq/L | 17 | 22-28 |
Anion gap, mEq/L | 16 | 8-12 |
Glucose, mg/dL | 427 | 70-100 |
BHB, mmol/L | 2.78 | 0.02–0.27 |
HbA1C, % | 10.2 | 4.0-5.6 |
Sodium, mEq/L | 126 | 135-145 |
AST, U/L | 94 | 10-40 |
ALT, U/L | 96 | 7-56 |
Total bilirubin, mg/dL | 4.5 | 0.1-1.2 |
Creatinine, mg/dL | 0.92 | 0.6-1.2 |
Urea, mg/dL | 37 | 7-20 |
WBC, ×109/L | 11.4 | 4.0-11.0 |
Hb, g/dL | 13 | 13-17 (Male) |
PLT, ×109/L | 131 | 150-400 |
C-peptide, ng/mL | 1.93 | 0.5-2.0 |
Anti-insulin Ab | Negative | Negative |
Anti-GAD Ab | Negative | Negative |
Management
The patient was admitted to the intensive care unit and treated with lactulose and intravenous insulin according to the DKA protocol. Regular insulin infusion was initiated at 0.1 units/kg/hour for the first three hours and subsequently reduced to 0.05 units/kg/hour until transition to subcutaneous insulin the following day.
The patient gradually improved over the next 48 hours and returned to his baseline mental status. At discharge, he was prescribed 100 units of long-acting insulin daily and 25 units of prandial insulin with each meal.
Discharge and Follow-up
The patient remained clinically stable after discharge. At three-month follow-up, HbA1c had decreased to 5.8%, and insulin requirements had progressively declined to 10 units of long-acting insulin alone. No hospital readmissions were reported during the year following discharge.
