Case Case PresentationPresentation

A 48 year old lady A 48 year old lady presenting with DKApresenting with DKA

Karuna Spiegelman, M.D.Karuna Spiegelman, M.D.

August 9, 2006August 9, 2006

History of present illnessHistory of present illness

Pat B is a 48 year old Type I diabetic Pat B is a 48 year old Type I diabetic who was transferred from Darlington who was transferred from Darlington ER, where she presented with 3 days ER, where she presented with 3 days of nausea, vomiting and intermittent of nausea, vomiting and intermittent chills. In the ER, she was found to chills. In the ER, she was found to have a blood sugar of 980, pH 6.96, have a blood sugar of 980, pH 6.96, pCO2 11.2, bicarbonate of 2.5. She pCO2 11.2, bicarbonate of 2.5. She was placed on an insulin drip and was placed on an insulin drip and transferred to Meriter Hospital. transferred to Meriter Hospital.

Review of systemsReview of systems

Most of the history is obtained from the Most of the history is obtained from the patient’s husband as the patient is patient’s husband as the patient is unable to provide us with any unable to provide us with any information as she is obtunded.information as she is obtunded.

The patient’s blood sugars have recently The patient’s blood sugars have recently been in the 400s, despite her taking been in the 400s, despite her taking insulin and other medications as she insulin and other medications as she usually does. She was drinking a lot of usually does. She was drinking a lot of water, but did not complain of chest water, but did not complain of chest pain, shortness of breath, cough, sputum pain, shortness of breath, cough, sputum production, abdominal pain, diarrhea.production, abdominal pain, diarrhea.

Past Medical HistoryPast Medical History

Diabetes mellitus Type I for 21 Diabetes mellitus Type I for 21 years. years.

Hypertension, well controlled.Hypertension, well controlled. Seizure disorder, no seizures for Seizure disorder, no seizures for

“many years” on Lamictal“many years” on Lamictal HysterectomyHysterectomy Breast lumpectomy, benignBreast lumpectomy, benign Right lung resection for “lung spots”Right lung resection for “lung spots”

AllergiesAllergies PenicillinPenicillin

MedicationsMedications

Glargine 10 units BIDGlargine 10 units BID Sliding scale insulin with HumalogSliding scale insulin with Humalog Hydrochlorothiazide 25 mg PO dailyHydrochlorothiazide 25 mg PO daily Quinine 5 mg PO prnQuinine 5 mg PO prn Lamictal 150 PO BIDLamictal 150 PO BID

Social History Social History

Pat is married and the mother of 2 Pat is married and the mother of 2 grown up children. She works as a grown up children. She works as a registered nurse at a clinic in registered nurse at a clinic in Darlington, WI. No history of Darlington, WI. No history of tobacco or alcohol or illicit drug use.tobacco or alcohol or illicit drug use.

Family HistoryFamily History

Both parents died of cancer of Both parents died of cancer of unknown primary. Siblings and unknown primary. Siblings and children healthychildren healthy

Physical Exam Physical Exam VITAL SIGNS: BP 98/46, HR 113, Temp 91.3, O2 Sat 99 % on RA. VITAL SIGNS: BP 98/46, HR 113, Temp 91.3, O2 Sat 99 % on RA. GEN APP: Obtunded middle-aged female breathing spontaneously, GEN APP: Obtunded middle-aged female breathing spontaneously,

answers yes or no to questions. answers yes or no to questions. HEENT: R pupil reactive 4mm HEENT: R pupil reactive 4mm 2 mm. L pupil sluggish and 2 mm. L pupil sluggish and

minimally reactive. No oral lesions. Tongue dry and cracked. No minimally reactive. No oral lesions. Tongue dry and cracked. No carotid bruits, JVD, thyromegaly or LAD. carotid bruits, JVD, thyromegaly or LAD.

LUNGS: CTA bilaterally. LUNGS: CTA bilaterally. HEART: Tachycardia. No gallops, murmurs, rubs, heaves or HEART: Tachycardia. No gallops, murmurs, rubs, heaves or

thrills. thrills. ABDOMEN: Hypoactive bowel sounds. Diffuse, mild to moderate ABDOMEN: Hypoactive bowel sounds. Diffuse, mild to moderate

tenderness.tenderness. EXTREMITIES: No c/c. No edema.EXTREMITIES: No c/c. No edema. SKIN: No rashes, echymoses or needle tracks. The skin does tent.SKIN: No rashes, echymoses or needle tracks. The skin does tent. NEUROLOGIC: As described above. She is moving all extremities. NEUROLOGIC: As described above. She is moving all extremities.

LabsLabs pH 6.96, CO2 11.2, PO2 144, HCO3 2.5, pH 6.96, CO2 11.2, PO2 144, HCO3 2.5,

base excess -29base excess -29 Na 146, K 4.2, Cl 109, CO2 5, BUN 70, Na 146, K 4.2, Cl 109, CO2 5, BUN 70,

creatinine 2.1, glucose 980 (calculated creatinine 2.1, glucose 980 (calculated effective Posm 346)effective Posm 346)

WBC 24.7, 90% neutrophils, 6% lymphs, 4% WBC 24.7, 90% neutrophils, 6% lymphs, 4% monos, HgB 14, Hct 43, plts 525 monos, HgB 14, Hct 43, plts 525

Alk phosAlk phos 189, albumin 4.3, total protein 7.6, 189, albumin 4.3, total protein 7.6, Ca 9.8, Mg 3.0, P 6.1, CK 22, Trop 0.06 (Nl)Ca 9.8, Mg 3.0, P 6.1, CK 22, Trop 0.06 (Nl)

UA: specific gravity 1.025, ketones>80, UA: specific gravity 1.025, ketones>80, protein 30, WBC 0-1, bacteria 1+. protein 30, WBC 0-1, bacteria 1+.

ImagingImaging

EKG: normal axis, sinus tachycardia, EKG: normal axis, sinus tachycardia, minimal ST depression. minimal ST depression.

CXR: no infiltrates, cardiomegaly, CXR: no infiltrates, cardiomegaly, pulmonary edema or pleural pulmonary edema or pleural effusions. effusions.

So, what is so interesting in a So, what is so interesting in a patient with DKA?????patient with DKA?????

Day # 3Day # 3

Pat has received 10 L of fluid.Pat has received 10 L of fluid. Anion gap has closed, electrolytes Anion gap has closed, electrolytes

are normalizing. are normalizing. She is still obtunded and minimally She is still obtunded and minimally

responsive.responsive.

Additional imagingAdditional imaging

Head CT: No acute process.Head CT: No acute process. Brain MRI: Multifocal ischemia in Brain MRI: Multifocal ischemia in

the left hemisphere: one in superior the left hemisphere: one in superior frontal white matter, one in the frontal white matter, one in the superior parietal lobe, one in deep superior parietal lobe, one in deep parietal subependymal region. No parietal subependymal region. No hemorrhage. hemorrhage.

Additional imagingAdditional imaging

MRI of the neck: Left internal carotid artery MRI of the neck: Left internal carotid artery has a small caliber as compared to the right. has a small caliber as compared to the right. This is a smoothly marginated process This is a smoothly marginated process extending the entire length of the left ICA. The extending the entire length of the left ICA. The left ICA is patent throughout the entire course.left ICA is patent throughout the entire course.

MRA of the brain: Diminutive presentation of MRA of the brain: Diminutive presentation of the left ICA. Dissection is not identified. Distal the left ICA. Dissection is not identified. Distal left ICA is has some suggestion of vessel wall left ICA is has some suggestion of vessel wall thickening, but no occlusion is seen along the thickening, but no occlusion is seen along the left ICA. Right ICA has relatively normal left ICA. Right ICA has relatively normal course and caliber. course and caliber.

Carotid artery stenosisCarotid artery stenosis

Carotid artery stenosisCarotid artery stenosis

DissectionDissection AtherosclerosisAtherosclerosis VasculitisVasculitis Fibromuscular dysplasiaFibromuscular dysplasia CongenitalCongenital

Carotid artery sclerosisCarotid artery sclerosis Prevalence in US: Prevalence in US: Estimates indicate that 5 Estimates indicate that 5

per 1000 persons aged 50-60 years and per 1000 persons aged 50-60 years and approximately 10% of persons older than 80 approximately 10% of persons older than 80 years have carotid stenosis greater than 50%. years have carotid stenosis greater than 50%.

Sex: ASex: Almost equal frequency in men and lmost equal frequency in men and women. In general, women are more likely to women. In general, women are more likely to seek and receive treatment for both benign seek and receive treatment for both benign and symptomatic carotid stenosis. and symptomatic carotid stenosis.

Age: Age: Extracranial carotid disease more Extracranial carotid disease more frequently in elderly persons. In patients with frequently in elderly persons. In patients with increased risk factors, the age at first increased risk factors, the age at first presentation tends to be younger presentation tends to be younger

SymptomsSymptoms Amaurosis fugax ( Temporary loss of vision in one Amaurosis fugax ( Temporary loss of vision in one

eye) eye) Transient ischemic attacks (TIA) Transient ischemic attacks (TIA) Reversible ischemic neurological deficits (RIND) Reversible ischemic neurological deficits (RIND) Cerebral vascular attack Cerebral vascular attack 75 % of people who suffer a stroke related to 75 % of people who suffer a stroke related to

carotid artery disease have a warning in the form of carotid artery disease have a warning in the form of a transient ischemic attack (TIA) prior to the stroke a transient ischemic attack (TIA) prior to the stroke

In patients older than 60 years who have cerebral In patients older than 60 years who have cerebral infarction, approximately 15% have ipsilateral infarction, approximately 15% have ipsilateral carotid stenosis of 70% or greater. In 40-50% of carotid stenosis of 70% or greater. In 40-50% of those with a complete stroke, the primary etiology those with a complete stroke, the primary etiology of the stroke is related to extracranial carotid of the stroke is related to extracranial carotid disease (stenosis).disease (stenosis).

Increased risk for MI Increased risk for MI

Risks Risks

Atherosclerosis Atherosclerosis HypertensionHypertension Smoking Smoking HyperlipidemiaHyperlipidemia Obesity Obesity DiabetesDiabetes Lack of regular exerciseLack of regular exercise Uncontrolled stress and anger Uncontrolled stress and anger

ImagingImaging

Duplex carotid sonographyDuplex carotid sonography CT angiography (CTA)CT angiography (CTA) Magnetic resonance angiography Magnetic resonance angiography

(MRA) of the carotid artery (MRA) of the carotid artery Carotid angiography Carotid angiography Oculoplethysmography. Measures the Oculoplethysmography. Measures the

arterial blood pressure in each eye arterial blood pressure in each eye and compares the readings to the and compares the readings to the blood pressure readings in each arm. blood pressure readings in each arm. Hardly used today.Hardly used today.

When to treatWhen to treat Symptomatic with 70 % stenosis. Carotid artery Symptomatic with 70 % stenosis. Carotid artery

repair reduces the 2 year risk of stroke from repair reduces the 2 year risk of stroke from 26% to 9%26% to 9%

Symptomatic with stenosis of 50-70% - still Symptomatic with stenosis of 50-70% - still benefit from repair. benefit from repair.

Asymptomatic if stenosis of 60% or greater (Asymptomatic if stenosis of 60% or greater (2020)) Stenosis of less than 50 % has no proven benefit Stenosis of less than 50 % has no proven benefit About 4 % of adults have asymptomatic neck About 4 % of adults have asymptomatic neck

bruits bruits Benefits of carotid endarterectomy are slightly Benefits of carotid endarterectomy are slightly

better in men than in women perhaps because better in men than in women perhaps because women have smaller arteries. women have smaller arteries.

When to treatWhen to treat

North American Symptomatic Carotid North American Symptomatic Carotid Endarterectomy Trial (NASCET) Collaborators. Endarterectomy Trial (NASCET) Collaborators. Beneficial effect of carotid endarterectomy in Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53. stenosis. N Engl J Med 1991;325:445-53.

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

Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, et al. Carotid endarterectomy and L, Hershey LA, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991;266:3289-94. carotid stenosis. JAMA 1991;266:3289-94.

TreatmentTreatment

Endovascular stenting and Endovascular stenting and angioplastyangioplasty

Catheter-directed thrombolytic Catheter-directed thrombolytic therapy (thrombosis)therapy (thrombosis)

Carotid endarterectomyCarotid endarterectomy

Follow-upFollow-up

So, what happened to Pat……So, what happened to Pat……

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

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

She continues to follow with her She continues to follow with her neurologist locally …..neurologist locally …..

DiscussionDiscussion

DKA and CVADKA and CVA Not often in the literature Not often in the literature More common in childrenMore common in children

Low threshold for head CT Low threshold for head CT Mostly cerebral edemaMostly cerebral edema

Second caseSecond case Is it more often than we think?Is it more often than we think?

ReferencesReferences North American Symptomatic Carotid Endarterectomy North American Symptomatic Carotid Endarterectomy

Trial (NASCET) Collaborators. Beneficial effect of Trial (NASCET) Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-high-grade carotid stenosis. N Engl J Med 1991;325:445-53. 53.

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

Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, et al. Carotid endarterectomy and Hershey LA, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991;266:3289-94. stenosis. JAMA 1991;266:3289-94.

(24) Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, (24) Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998;339:1415-25. or severe stenosis. N Engl J Med 1998;339:1415-25.

References cont’dReferences cont’d CASANOVA Study Group. Carotid surgery versus CASANOVA Study Group. Carotid surgery versus

medical therapy in asymptomatic carotid stenosis. medical therapy in asymptomatic carotid stenosis. Stroke 1991;22:1229-35. Mayo Asymptomatic Carotid Stroke 1991;22:1229-35. Mayo Asymptomatic Carotid Endarterectomy Study Group. Results of a Endarterectomy Study Group. Results of a randomized controlled trial of carotid endarterectomy randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Clin Proc for asymptomatic carotid stenosis. Mayo Clin Proc 1992;67:513-8. 1992;67:513-8.

Hobson RW 2d, Weiss DG, Fields WS, Goldstone J, Hobson RW 2d, Weiss DG, Fields WS, Goldstone J, Moore WS, Towne JB, et al. Efficacy of carotid Moore WS, Towne JB, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N endarterectomy for asymptomatic carotid stenosis. N Engl J Med 1993;328:276-9. Engl J Med 1993;328:276-9.

Executive Committee for the Asymptomatic Carotid Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA asymptomatic carotid artery stenosis. JAMA 1995;273:1421-8. 1995;273:1421-8.

References cont’dReferences cont’d

http://www.emedicine.com/EMERG/http://www.emedicine.com/EMERG/topic135.htmtopic135.htm

http://www.emedicine.com/radio/topic1http://www.emedicine.com/radio/topic133.htm33.htm

http://www.mayoclinic.org/carotid-arterhttp://www.mayoclinic.org/carotid-artery-disease/index.htmly-disease/index.html

http://www.mayoclinic.org/carotid-arterhttp://www.mayoclinic.org/carotid-artery-disease/treatment.htmly-disease/treatment.html

http://www.aafp.org/afp/20000115/400.http://www.aafp.org/afp/20000115/400.htmlhtml