Case Presentation

A 48 year old lady presenting with

DKA

Karuna Spiegelman, M.D.

August 9, 2006
 History of present illness
Pat B is a 48 year old Type I diabetic who was
transferred from Darlington ER, where she
presented with 3 days of nausea, vomiting and
intermittent chills. In the ER, she was found to
have a blood sugar of 980, pH 6.96, pCO2 11.2,
bicarbonate of 2.5. She was placed on an insulin
drip and transferred to Meriter Hospital.
 Review of systems
Most of the history is obtained from the patients
husband as the patient is unable to provide us
with any information as she is obtunded.
The patients blood sugars have recently been in
the 400s, despite her taking insulin and other
medications as she usually does. She was
drinking a lot of water, but did not complain of
chest pain, shortness of breath, cough, sputum
production, abdominal pain, diarrhea.
 Past Medical History
Diabetes mellitus Type I for 21 years.
Hypertension, well controlled.
Seizure disorder, no seizures for many years
on Lamictal
Hysterectomy
Breast lumpectomy, benign
Right lung resection for lung spots
 Allergies
Penicillin

Medications
Glargine 10 units BID
Sliding scale insulin with Humalog
Hydrochlorothiazide 25 mg PO daily
Quinine 5 mg PO prn
Lamictal 150 PO BID
 Social History
Pat is married and the mother of 2 grown up
children. She works as a registered nurse at a
clinic in Darlington, WI. No history of tobacco
or alcohol or illicit drug use.

Family History
Both parents died of cancer of unknown primary.
Siblings and children healthy
 Physical Exam
VITAL SIGNS: BP 98/46, HR 113, Temp 91.3, O2 Sat 99 % on RA.
GEN APP: Obtunded middle-aged female breathing spontaneously,
answers yes or no to questions.
HEENT: R pupil reactive 4mm 2 mm. L pupil sluggish and
minimally reactive. No oral lesions. Tongue dry and cracked. No
carotid bruits, JVD, thyromegaly or LAD.
LUNGS: CTA bilaterally.
HEART: Tachycardia. No gallops, murmurs, rubs, heaves or thrills.
ABDOMEN: Hypoactive bowel sounds. Diffuse, mild to moderate
tenderness.
EXTREMITIES: No c/c. No edema.
SKIN: No rashes, echymoses or needle tracks. The skin does tent.
NEUROLOGIC: As described above. She is moving all extremities.
 Labs
pH 6.96, CO2 11.2, PO2 144, HCO3 2.5, base excess -
29
Na 146, K 4.2, Cl 109, CO2 5, BUN 70, creatinine 2.1,
glucose 980 (calculated effective Posm 346)
WBC 24.7, 90% neutrophils, 6% lymphs, 4% monos,
HgB 14, Hct 43, plts 525
Alk phos 189, albumin 4.3, total protein 7.6, Ca 9.8,
Mg 3.0, P 6.1, CK 22, Trop 0.06 (Nl)
UA: specific gravity 1.025, ketones>80, protein 30,
WBC 0-1, bacteria 1+.
 Imaging
EKG: normal axis, sinus tachycardia, minimal
ST depression.
CXR: no infiltrates, cardiomegaly, pulmonary
edema or pleural effusions.
So, what is so interesting in a patient with
DKA?????
 Day # 3

Pat has received 10 L of fluid.

Anion gap has closed, electrolytes are
normalizing.
She is still obtunded and minimally responsive.
 Additional imaging
Head CT: No acute process.
Brain MRI: Multifocal ischemia in the left
hemisphere: one in superior frontal white
matter, one in the superior parietal lobe, one in
deep parietal subependymal region. No
hemorrhage.
 Additional imaging
MRI of the neck: Left internal carotid artery has a small
caliber as compared to the right. This is a smoothly
marginated process extending the entire length of the
left ICA. The left ICA is patent throughout the entire
course.
MRA of the brain: Diminutive presentation of the left
ICA. Dissection is not identified. Distal left ICA is has
some suggestion of vessel wall thickening, but no
occlusion is seen along the left ICA. Right ICA has
relatively normal course and caliber.
Carotid artery stenosis
 Carotid artery stenosis
Dissection
Atherosclerosis
Vasculitis
Fibromuscular dysplasia
Congenital
 Carotid artery sclerosis
Prevalence in US: Estimates indicate that 5 per 1000
persons aged 50-60 years and approximately 10% of
persons older than 80 years have carotid stenosis
greater than 50%.
Sex: Almost equal frequency in men and women. In
general, women are more likely to seek and receive
treatment for both benign and symptomatic carotid
stenosis.
Age: Extracranial carotid disease more frequently in
elderly persons. In patients with increased risk factors,
the age at first presentation tends to be younger
 Symptoms
Amaurosis fugax ( Temporary loss of vision in one eye)
Transient ischemic attacks (TIA)
Reversible ischemic neurological deficits (RIND)
Cerebral vascular attack
75 % of people who suffer a stroke related to carotid artery
disease have a warning in the form of a transient ischemic attack
(TIA) prior to the stroke
In patients older than 60 years who have cerebral infarction,
approximately 15% have ipsilateral carotid stenosis of 70% or
greater. In 40-50% of those with a complete stroke, the primary
etiology of the stroke is related to extracranial carotid disease
(stenosis).
Increased risk for MI
 Risks
Atherosclerosis
Hypertension
Smoking
Hyperlipidemia
Obesity
Diabetes
Lack of regular exercise
Uncontrolled stress and anger
 Imaging
Duplex carotid sonography
CT angiography (CTA)
Magnetic resonance angiography (MRA) of the
carotid artery
Carotid angiography
Oculoplethysmography. Measures the arterial
blood pressure in each eye and compares the
readings to the blood pressure readings in each
arm. Hardly used today.
 When to treat
Symptomatic with 70 % stenosis. Carotid artery repair
reduces the 2 year risk of stroke from 26% to 9%
Symptomatic with stenosis of 50-70% - still benefit
from repair.
Asymptomatic if stenosis of 60% or greater (20)
Stenosis of less than 50 % has no proven benefit
About 4 % of adults have asymptomatic neck bruits
Benefits of carotid endarterectomy are slightly better in
men than in women perhaps because women have
smaller arteries.
 When to treat

North American Symptomatic Carotid Endarterectomy Trial

(NASCET) Collaborators. Beneficial effect of carotid
endarterectomy in symptomatic patients with high-grade carotid
stenosis. N Engl J Med 1991;325:445-53.
European Carotid Surgery Trialists' Collaborative Group. MRC
European Carotid Surgery Trial: interim results for symptomatic
patients with severe (70-99%) or with mild (0-29%) carotid
stenosis. Lancet 1991;337:1235-43.
Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L,
Hershey LA, et al. Carotid endarterectomy and prevention of
cerebral ischemia in symptomatic carotid stenosis. JAMA
1991;266:3289-94.
 Treatment
Endovascular stenting and angioplasty
Catheter-directed thrombolytic therapy
(thrombosis)
Carotid endarterectomy
 Follow-up
So, what happened to Pat

Day # 3 (after we obtained the MRI) she woke up

Rheumatology - vasculitis?
Neurology - rapid and remarkable recovery
Neurosurgery - stenting v/s bypass

She continues to follow with her neurologist locally ..

 Discussion
DKA and CVA
Not often in the literature
More common in children
Low threshold for head CT
Mostly cerebral edema

Second case
Is it more often than we think?
 References
North American Symptomatic Carotid Endarterectomy Trial
(NASCET) Collaborators. Beneficial effect of carotid
endarterectomy in symptomatic patients with high-grade carotid
stenosis. N Engl J Med 1991;325:445-53.

European Carotid Surgery Trialists' Collaborative Group. MRC

European Carotid Surgery Trial: interim results for symptomatic
patients with severe (70-99%) or with mild (0-29%) carotid
stenosis. Lancet 1991;337:1235-43.

Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey

LA, et al. Carotid endarterectomy and prevention of cerebral
ischemia in symptomatic carotid stenosis. JAMA 1991;266:3289-94.

(24) Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG,
Haynes RB, et al. Benefit of carotid endarterectomy in patients with
symptomatic moderate or severe stenosis. N Engl J Med
1998;339:1415-25.
 References contd
CASANOVA Study Group. Carotid surgery versus medical therapy
in asymptomatic carotid stenosis. Stroke 1991;22:1229-35. Mayo
Asymptomatic Carotid Endarterectomy Study Group. Results of a
randomized controlled trial of carotid endarterectomy for
asymptomatic carotid stenosis. Mayo Clin Proc 1992;67:513-8.

Hobson RW 2d, Weiss DG, Fields WS, Goldstone J, Moore WS,

Towne JB, et al. Efficacy of carotid endarterectomy for
asymptomatic carotid stenosis. N Engl J Med 1993;328:276-9.

Executive Committee for the Asymptomatic Carotid Atherosclerosis

Study. Endarterectomy for asymptomatic carotid artery stenosis.
JAMA 1995;273:1421-8.
 References contd
http://www.emedicine.com/EMERG/topic135.htm
http://www.emedicine.com/radio/topic133.htm
http://www.mayoclinic.org/carotid-artery-
disease/index.html
http://www.mayoclinic.org/carotid-artery-
disease/treatment.html
http://www.aafp.org/afp/20000115/400.html