Objective : Triglyceride induced pancreatitis (TIP) is a relatively rare cause of pancreatitis, responsible for 1-14% of acute pancreatitis cases. The combined presentation of TIP with DKA is exceedingly rare with only a handful of cases in the literature. We present a novel case of a patient who presented with TIP and DKA leading to a new diagnosis of autoimmune diabetes (AIDM).
Methods : N/A
A 25 year old Vietnamese male with no past medical history presented in 2016 with vomiting and epigastric abdominal pain for 1 day. Lipase was elevated at 326 U/L (13-60 U/L), serum glucose 653 mg/dL, bicarbonate 20 mmol/L, large urine ketones and hemoglobin A1c 10.7%. Abdominal CT was consistent with acute pancreatitis. Patient’s initial triglyceride level was 651 mg/dL, 12 hours after insulin infusion was begun. Patient was discharged from the hospital on gemfibrozil and metformin. Discharge summary documents “most likely T2DM.”
Patient returned to the hospital 29 months later with sudden onset severe epigastric pain. Lipase was 576 U/L (73-393 U/L), triglycerides 8002 mg/dL, glucose 416 mg/dL and large urinary ketones, HbA1c 8.4%, BMI 36 kg/m2. Patient stopped previously prescribed metformin because “I was told I didn’t have diabetes anymore.” Given multiple DKA admissions in a young patient, we had concern for AIDM. Antibody testing with GAD-65 and IA-2 were negative however Zinc Transporter 8 antibody was elevated at 36 U/mL (<15 U/ml). Patient was diagnosed with AIDM and discharged with basal/bolus insulin as well as gemfibrozil.
TIP with DKA is a relatively rare presentation, especially as an initial presentation of autoimmune diabetes, likely secondary to LADA in this patient. One case series showed that 11% of DKA patients had acute pancreatitis on admission, with one-third of those (4% total) being related to elevated triglycerides. Our case demonstrates a high index of suspicion for AIDM is necessary to ensure patients are on proper therapy. Isolated ZnT-8 antibody positivity is relatively rare, accounting for just 3% of antibody positive cases in one study.
Further studies are necessary to determine if the hypertriglyceridemia is a result of hyperglycemia or possibly related to a separate pathophysiological condition.
Temple University Hospital
Dr. Miller is a first year endocrine fellow at Temple University Hospital. After earning his medical degree from the Albert Einstein College of Medicine in 2015, Dr. Miller moved to Philadelphia to pursue internal medicine training at Temple University Hospital. Among his many interests in endocrinology, Dr. Miller is especially passionate about diabetes treatment and management. He appreciates the many opportunities to facilitate student and resident education that are presented to him and is looking forward to a career dedicated to education and patient care.
Clinical Assistant Professor of Medicine
Lewis Katz School of Medicine at Temple University
Dr. Criner received her BS in Biology from the University of Pittsburgh and then proceeded to earn her medical degree from the Lewis Katz School of Medicine. She returned to Pittsburgh for her internal medicine and endocrine training, both at UPMC. Since finishing fellowship, Dr. Criner has been in practice at Temple University Hospital. Among her many accomplishments, Dr. Criner has been an integral part of the post-transplant care for the patient's of the busy Temple Lung Center setting up an endocrine clinic dedicated specifically to the unique needs of these patients.