Diabetic ketoacidosis complicated by supraventricular tachycardia in a young adult: a case report

Diabetic ketoacidosis (DKA) is one of the most common serious metabolic complications of diabetes in adolescents and young adults. Complications are due to metabolic acidosis, electrolyte abnormalities, acute renal failure and respiratory distress. Serum electrolyte abnormalities are common in DKA. Such serum electrolyte alterations, including acidosis, have been associated with the development of cardiac arrhythmias. We report the case of a 29-year-old man whose parents have diabetes mellitus. His illness began six months earlier with a weight loss of 15 kg. He did not seek for medical attention. The patient presented in a family medical unit with drowsiness and dehydration. On examination, his blood pressure was 90/60 mmHg, pulse rate 216 beats/minute, respiratory rate 32 cycles/minute, and temperature 36.5°C. His random blood glucose was 458 mg/dL with ketonuria. His electrocardiogram showed supraventricular tachycardia. He was referred to a second level hospital where he was admitted into the Intensive Care Unit (ICU) after three hours of stabilization. The patient was discharged in good condition 11 days after his admission to the hospital and was to continue treatment with glargine insulin (1 UI/kg) at home. He was also advised on healthy nutrition, blood glucose target of 150 mg/dL and follow-up in the Outpatient Department of Cardiology and Internal Medicine. 156 Ayón-Aguilar et al. Investigación Clínica 59(2): 155 160, 2018 Cetoacidosis diabética complicada con taquicardia supraventricular en un joven adulto. Invest Clin 2018; 59 (2): 155 160 Resumen. La cetoacidosis diabética (CAD) es una de las más comunes complicaciones serias de la diabetes en adolescentes y adultos jóvenes. Las complicaciones son debidas a la acidosis metabólica, anormalidades electrolíticas, falla aguda renal y distrés respiratorio. Las alteraciones hidroelectrolíticas son muy comunes en la CAD. Estas alteraciones, junto con la acidosis, han sido asociadas al desarrollo de arritmias. Se reporta el caso de un paciente de 29 años de edad con antecedente de padres diabéticos. Su condición comenzó 6 meses antes con pérdida de peso de aproximadamente 15 kg, astenia y adinamia, sin haber recibido ninguna atención médica. El paciente fue recibido en su Unidad de Medicina Familiar somnoliento y deshidratado, con TA: 90/60, FR: 32x’, FC: 216x’, T: 36.5GC, glucosa de 458 mg/dL y cetonuria. Su electrocardiograma mostró taquicardia supraventricular. Trasladado a un segundo nivel de atención en hospital, el paciente fue inmediatamente transferido al Área de Reanimación e ingresado a la Unidad de Cuidados Intensivos posterior a 3 horas de estabilización. El paciente fue egresado en buenas condiciones 11 días después de su admisión al hospital con tratamiento a base de insulina glargina (1 UI/kg), y medidas higiénico-dietéticas, glucosa de 150 mg/dL, con seguimiento como paciente externo en los Servicios de Cardiología y Medicina Interna. Palabras clave: cetoacidosis diabética; taquicardia supraventricular; alteraciones cardiovasculares. Recibido: 30-08-2017 Aceptado: 15-02-2018 (5). DKA is usually accompanied by severe dehydration, catecholamine release and alterations in the potassium homeostasis. The most frequent causes of DKA are infections and poor adherence to treatment (6). The complications of DKA are alterations due to metabolic acidosis, electrolyte abnormalities, acute renal failure and respiratory distress. Although electrolyte abnormalities are common in DKA, cardiac arrhythmias are rare. The cardiovascular abnormalities in DKA are due to adverse effects of the acidosis and arrhythmias caused by electrolyte disturbances. In models of myocardial cells, the repolarization can be inhibited by the acidosis. The action potential represents a delicate balance between ions, which can be disturbed by the acidosis. The underlying INTRODUCTION Diabetic ketoacidosis (DKA) is one of the most common and serious metabolic complications of diabetes mellitus in adolescents and young adults. It may be the first manifestation of a new-onset diabetes mellitus (1, 2). In 2009, there were approximately 140,000 hospitalizations for DKA, costing more than 1 million dollars in hospitalizations per year in the United States of America (3). Fifty-six percent of patients are between 18 and 44 years-old. The prognosis of the DKA worsens in the extremes of life and in the presence of a coma state, hypotension and serious comorbidities (4). In adults with DKA, the mortality at global and national levels is between 5% and 10% Diabetic ketoacidosis complicated by supraventricular tachycardia 157 Investigación Clínica 59(2): 155 160, 2018 mechanisms that bring about the changes in the action potential are poorly understood (7). The effects of acidosis on the heart depend on the pH level. These effects can be an increment in the release of catecholamine, which translates into increased inotropism, chronotropism, cardiac output and peripheral vascular resistance. When pH is less than 7.2, H+ ions have a direct depressing action on the heart and it may be associated with decreased cardiac contractility and a predisposition to cardiac arrhythmias, all of which may contribute to hemodynamic instability (8). The acidosis is the key clinical feature found in DKA that can precipitate arrhythmias. Orchard and Cingolani (9), describe the arrhythmogenic consequences of the acidosis such as the re-entry and early repolarization. Youssef and Farid (10) demonstrated how the ketosis may cause arrhythmias due to alterations in driving the action potential. On the other hand, a study conducted by Süfke et al. (11), observed ventricular and supraventricular arrhythmias in 12 patients (10 with DKA and 2 with hyperglycemic hyperosmolar state). The autonomic dysfunction resulting from the high levels of glucose was believed to be the root cause of the arrhythmias (11, 12). The potassium deficit is one of the most important electrolyte abnormalities found in the DKA, which could lead to severe arrhythmias. In 2014, Wolfsdorf et al. (13) concluded that a cardiac monitor should be used for continuous electrocardiographic monitoring to assess T waves for evidence of hyper or hypokalemia in patients with DKA. We can also find other electrolyte abnormalities such as hypophosphatemia that can precipitate cardiac arrhythmias (14). The greater part of these arrhythmias is by re-entry, polymorphic atrial fibrillation (AF), ventricular tachycardia (VT) and ventricular fibrillation (VF), premature atrial contractions, atrial tachycardia with or without atrioventricular (AV) block, supraventricular tachycardia (SVT) and premature ventricular contraction (15). SVT in the DKA can be due to different abnormalities in the formation of the cardiac electrical impulse (16). DKA associated with cardiac complications, such as the SVT, is rarely seen in clinical practice. There are three cases reported in the world’s literature: Thomas et al. with two cases in 2007 (16) and Faruqi et al. with one case in 2015 (1). SVT is probably a result of the electrolyte and ketoacidosis abnormalities. However, a multifactorial etiology resulting in the development of SVT is very possible (1). This Case Report is important and relevant with the potential of raising the alertness of physicians to improve care and prognosis in patients with DKA. The key lesson of this Case Report is to perform electrocardiogram to all patients with DKA in order to detect and treat cardiac arrhythmias such as SVT which may occur as a complication of metabolic and electrolyte disturbances which are present in these patients.