37 years old samy
sayed Ex-smoker;20 cigarette per day for
28 years, works in restaurant , Complaining of disturbed Consciousness
Associated with dizziness, nausea, vomiting, weight loss and abdominal pain 4th
time with no fever 20 days ago. On physical Examination, hepatomegaly with no
dilated vein, no scar, no splenomegaly, no jaundice and reveal loss of
sensation of both dorsum of the foot only, no other system are affected. From
the history of patient, when he was 9
years old went to hospital due to his tiredness, week, and polyuria for the
first time and blood test shown sugar around 500 mg/dl and prescribed insulin 3
times per day than after one year he lost consciousness than after two years
again than.... 4th time with association .
To understand this
case needs some theoretical knowledge about hyperglycemia and also liver, fatty
tissue and pancreas consist of Beta cells and other cells. Liver is an organ,
glucose container in the form of glycogen and releaser as release the glucose
into blood stream. About pancreas; it releases the both insulin hormones and
glucagon hormones in a feedback way. Fatty tissue is made by fatty cells that
release the fatty acid into bloodstream. Blood circulates into all our body tissues
including liver and pancreas.
When we eat the
carbohydrates containing foods including glucose, this glucose enter into
bloodstream and meet to liver cells here it is stored as glycogen for future or
later needed and also to the fatty tissue or adipose tissue. High blood glucose
level call or stimulate the pancreas to release the insulin for reducing blood
glucose level to normal or stable level taken up by skeletal muscles, adipose tissue and
liver through action of insulin. Once pancreas is unable to release the insulin
, glucose level become high and high ,
none of our body system can prevent except the insulin. only insulin can reduce
the blood glucose levels but in the other hand , glucose can be released by
Glucagon, growth hormone and cortisol. Thus insulin and glucagon work here as a
feedback system for the blood glucose. Destruction of pancreatic beta cells by
autoantibody lead the pancreas unable to release insulin ; as a result no
insulin in the blood but glucose always present and increasing due to no insulin and eating glucose containing
foods. Only the autoantibody is the responsible for this hyperglycemic state
but origin of autoantibody is still unknown. Insulin suppresses the glucose
production from liver and other sources and also by taken up glucose by muscle,
liver and adipose tissue etc.
This hyper
glycemic state is called "Type | Diabetes Mellitus". This Glucose is unable to use for energy
production due to not taken up by tissues. but we got the energy from different
way like , in the absence of insulin , fatty tissue release the free fatty acid
and it is converted into ketone bodies and acetoacetate, beta hydroxybutarate
for energy that needs for activity ,also it occurs during starvation.
but problem here
is the ketone body that shows the clinical symptoms as medical emergency like,
Nausea,Vomiting, abdominal pain and coma on top of type one DM. all events here
is defined as DKA. Clinical symptoms for the hyperglycemia are polyuria due to
glucosuria that take the water and solutes along glucose, Dehydration due to
loss of water, weight loss, polydipsia, and Polyphagia. So, in this patient
only one problem that is no insulin due to destruction of beta cells due to
autoantibody is showing all the clinical symptoms. Now it is very clear that
what is the Management in this patient?
Management depends on the Complications as Symptoms of DKA,
Investigations, main etiology and treatment based on response. For the Dehydration,
prescribed IV Fluid, for the no insulin, give insulin, for the pain give analgesic,
these are the main line of treatment. Also surgical like pancreas
transplantation or beta cell transplantation. For the autoantibody, give immune suppressive drugs especialy if kidney involved as impaired function.
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