Sepsis in Type 1 Diabetes Mellitus with Diabetic Ketoacidosis

Dinda Aprilia

, Eva Decroli

, Alexander Kam

, Afdol Rahmadi

, Asman Manaf

and Syafril Syahbuddin

Departement of Internal Medicine, Faculty of Medicine, Universitas Andalas- M. Djamil General Hospital, Padang,

Sumatera Barat, Indonesia.

Keywords: Diabetic Ketoacidosis, Diabetes Mellitus, Sepsis.

Abstract: Introduction: Infection is the most common predisposing factor for the development of a hyperglycemic

crisis, which is diabetic ketoacidosis (DKA). Type 1 diabetes mellitus patients have a higher risk of

infection than type 2 diabetes mellitus patients. Method: Case report Results: A 19-year-old man presented

with decreased consciousness. Before he was unconscious, the patient complained of vomiting,

breathlessness, cough, and fever. There was no family history of diabetes mellitus. On general examination,

he appeared with soporous, Kussmaul breathing with the respiratory rate was 34 times/minute, blood

pressure was 130/80 mmHg, pulse rate was 115 beats/minute, and the temperature was 38.4˚C. His body

mass index was 18.49. There were rales in the pulmonary examination. Laboratory investigation results

were as follows: hemoglobin 13.8 gr/dl; white blood cell count 16.900/ mm

; random blood glucose 589

mg/dl; HbA

c 14.06%; C-peptide 0.2 ng/ml; creatinine 1,0 mg/dl; metabolic acidosis in arterial blood gas;

ketouria +++. Thorax x-ray confirmed pneumonia in this patient. Patient treated with DKA management and

sepsis. On the second day, the treatment of DKA was resolved and continued with the administration of

short-acting insulin and regular long acting. Conclusion: Type 1 diabetes mellitus patients are more

susceptible to infection than type 2 diabetes mellitus patients. Education and management strategies with

both patients and their caregivers are important to improve the glycemic control and reduce the risk of

developing severe infections and poor treatment outcomes.

1 INTRODUCTION

Infection is the most common predisposing factor

for the development of a hyperglycemic crisis,

which is diabetic ketoacidosis (DKA) (Azoulay,

2001). Among the predisposing factors for DKA,

infection is the most common cause of death (Duca,

2017). Commonly reported bacterial infections in

diabetes patients in Japan have included infections

of the respiratory system, kidney and urinary tract,

and skin and soft tissue (Shizuma, 2016).

Type 1 diabetes mellitus patients have a higher

risk of infection than type 2 diabetes mellitus

patients (Carey, 2018). Poor glycemic control is

susceptible to severe bacterial infections and

complications such as DKA, which may in turn

further exacerbate the bacterial infection (Decroli,

2018). DKA is precipitated or complicated by

infections in 75% of the cases. The mortality rate of

patients with DKA and infections is 43% (Simonsen,

2015).

1.1 Case Summary

A 19-year-old man presented with decreased

consciousness in the last 1 hour before admission.

Before he was unconscious, his family told that the

patient complained of vomiting, breathlessness,

cough, and fever. His body weight was decreased by

10 kilograms in 1 month. There was no family

history of diabetes mellitus.

On general examination, he appeared with

soporous, Kussmaul breathing with the respiratory

rate was 34 times/minute, blood pressure was 130/80

mmHg, pulse rate was 115 beats/minute, and the

temperature was 38.4˚C. His body mass index was

18.49. There were rales in the pulmonary

examination. There were no cardiovascular

abnormalities and no peripheral edema found.

Laboratory investigation results were as follows:

hemoglobin 13.8 gr/dl; white blood cell count

16.900/ mm

; random blood glucose 589 mg/dl;

HbA

c 14.06%; C-peptide 0.2 ng/ml; creatinine 1,0

Aprilia, D., Decroli, E., Kam, A., Rahmadi, A., Manaf, A. and Syahbuddin, S.

Sepsis in Type 1 Diabetes Mellitus with Diabetic Ketoacidosis.

DOI: 10.5220/0009859200720074

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 72-74

ISBN: 978-989-758-469-5

mg/dl; metabolic acidosis in arterial blood gas;

ketouria +++. Thorax x-ray confirmed pneumonia in

this patient.

The patient was hospitalized with a diagnosis of

sepsis because of community-acquired pneumonia,

diabetic ketoacidosis, and type 1 diabetes mellitus.

Broad spectrum antibacterial therapy was initiated to

treat sepsis and pneumonia. Diabetic ketoacidosis

was treated with administration of saline hydration

and continuous insulin infusion. Bicarbonate was

administered to treat acidosis. The patient has

responded to the therapies. Several hours after

admission, the patient began to conscious, the

respiratory rate was down to the normal rate,

acidosis has been treated, and the blood glucose

level has been controlled. The day after admission,

saline hydration and insulin infusion were

discontinued. Intensive control of blood glucose was

achieved with subcutaneous injection of short-acting

insulin before each meal and long-acting insulin at

bedtime. Dietary and patient education for self-

administration of insulin injection was done.

2 DISCUSSION

Diabetes is one of the leading causes of morbidity

and mortality across the globe, and the burden of

disease is projected to increase from 425 to 629

million adults between 2017 and 2045 (Decroli,

2019). The association between diabetes and

infection is well known clinically and has been

linked to a number of the causal pathway. Patients

with diabetes are susceptible to infection because of

the decreased migratory ability of neutrophils,

decreased phagocytic activity, impaired humoral

immunity, increased adherence of microorganisms

to diabetic cells, neuropathy, and microangiopathy

(Hong, 2015).

Organ systems where bacterial infections

predominate as well as fungal diseases were

associated with substantial increases in magnitude

among patients with both T1DM and T2DM, but

risks were consistently higher for T1DM. Patients

with T1DM are at approximately double the risk of

patients with T2DM for infection-related to death.

Bacterial eradication is needed to treat the infection.

Antibiotic regimens are not different in a patient

with or without diabetes (Azoulay, 2001).

Lung infections suffered by these patients trigger

sepsis which then increases the risk of diabetic

ketoacidosis. DKA management must be carried out

quickly and precisely given the high mortality rate.

DKA management protocols are replacement of lost

fluids and salts, administration of insulin and

management of infection. Considering that severe

acidosis can interfere with the balance of

homeostasis, it is reasonable to treat patients with

pH <7.0 using sodium bicarbonate. DKA in these

patients can be resolved well because of the

provision of therapy in accordance with the protocol,

which are fluid resuscitation, blood sugar control

and infection management with the administration of

broad-spectrum antibiotics, which is the third

generation of cephalosporin (Cheng, 2016).

After DKA is controlled, the important thing to

trace is diabetes newly known by the patient. The

classification of diabetes suffered by patients must

be traced in view of management strategies that

must be prepared to prevent recurrent DKA. Type 1

DM usually occurs at the age of children (<12

years), while type 2 DM usually occurs in adults (>

40 years). Therefore, in tracing the diagnosis we

need to ascertain the cause of diabetes in these

patients whether due to absolute insulin deficiency

or because of insulin resistance (Carey 2018).

Further examination is needed to rule out the

possibility of other types of diabetes, which are

HOMA-IR, C-peptide, and pancreatic x-ray.

HOMA-IR examination is performed to assess the

presence of insulin resistance. C-peptide to assess

insulin deficiency. Pancreatic x-ray to see

calcification in the pancreas that appears in

malnutrition-related diabetes mellitus (Cheng,

2016).

From the results of the examination, normal

HOMA-IR was obtained which means there was no

insulin resistance in the patient and low C-peptide

which illustrates the low insulin secretion due to

damage to the pancreatic beta cells. This removes

the diagnosis of type 2 diabetes in these patients. On

examination of pancreatic X-ray, no calcification

was found in the pancreatic projection, so the

diagnosis of malnutrition-related diabetes mellitus

was also excluded. However, the diagnosis of other

types of diabetes in these patients still cannot be

excluded because genetic testing is still needed

(Carey, 2018).

The management of type 1 DM includes

administration of insulin, dietary management,

exercise, and education. The entire component must

run in an integrated strategy to get good metabolic

control. The main goal of managing diabetic patients

is the ability to manage the disease independently.

Good glycemic control is needed to reduce the risk

of infections that have threatened type 1 DM

patients (Simonsen, 2015).

Sepsis in Type 1 Diabetes Mellitus with Diabetic Ketoacidosis

3 CONCLUSION

Type 1 diabetes mellitus patients are more

susceptible to infection than type 2 diabetes mellitus

patients. Education and management strategies with

both patients and their caregivers are important to

improve the glycemic control and reduce the risk of

developing severe infections and poor treatment

outcomes.

CONFLICT OF INTEREST

None.

REFERENCES

Amiel S, Lawrence, RD, Pursey, N, Higgins, B, Dawoud,

D. 2015. Diagnosis and management of type 1

diabetes mellitus: summary of updated NICE

guidance. British Medical Journal. 351:h4188.

Azoulay E, Chevret S, Didier J, Neuville S, Barboteu M,

Bornstain C, et al. Infection as a trigger of diabetic

ketoacidosis in intensive-care-unit patients. 2001.

Clinical Infectious Diseases. 32(1):30-5.

Carey IM, Critchley JA, DeWilde S, Harris T, Hosking FJ,

Cook DG, et al. 2018. Risk of infection in type 1 and

type 2 diabetes compared with the general population:

a matched cohort study. Diabetes Care. 41(3):513-21.

Cheng Y, Huang C, Lin W, Lu P, Chang K, Tsai J, et al.

2016. Clinical outcomes of septic patients with

diabetic ketoacidosis between 204 and 2013 in a

tertiary hospital in Taiwan. Journal of Microbiology,

Immunology, and Infection. 49(5):663-71.

Decroli E, Manaf A, Syahbuddin S, Syafrita Y,

Dillasamola D. 2019. The correlation between

malondialdehyde and nerve growth factor serum level

with diabetic peripheral neuropathy score. Open

Access Macedonian Journal of Medical Sciences.

7(1):103-6.

Decroli E, Manaf A, Syahbuddin S, Waspadji S,

Dillasamola D. 2018. The role of surviving and raf-1

kinase against enhancement of pancreatic beta-cell

apoptosis in patients with type 2 diabetes mellitus.

Asian Journal of Pharmaceutical and Clinical

Research. 11(11):344-7.

Duca LM, Wang B, Rewers M, Rewers A. 2017. Diabetic

ketoacidosis at diagnosis of type 1 diabetes predicts

poor long-term glycemic control. Diabetes Care.

40(9):1249-55.

Hong JY, Jalaludin MY, Adam BM, Fuziah MZ, Wu LL,

Rasat R, et al. 2015. Diabetes ketoacidosis at

diagnosis of type 1 diabetes mellitus in Malaysian

children and adolescents. Malays Fam Physician.

10(3):11-8.

Shizuma T, Fukui S, Todoroki K. 2016. A case of the back

abscess and diabetic ketoacidosis in a patient with type

2 diabetes mellitus. Diabetes Care Rep. 1(2):1-3.

Simonsen JR, Harjutsalo V, Jarvinen A, Kirveskari J,

Forsblom C, Groop P, et al. 2015. Bacterial infection

in patients with type 1 diabetes: a 14-year follow-up

study. BMJ Open Diabetes Research & Care.

3:e000067.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease