SAT-682 Unusual Presentation of Diabetic Ketoacidosis Associated with Hypernatremia in Adult Patient

Diabetic ketoacidosis (DKA) is an acute, life threatening complication of diabetes characterized by hyperglycemia, ketonemia and acidosis. It is known to commonly present with hyponatremia and rarely with hypernatremia. DKA can present with hypernatremia in pediatric population which carries poor prognosis when present. We present a 27 year- old Ethiopian lady, previously healthy who was brought to emergency department (ED) with decreased level of consciousness. She had polyuria and polydipsia associated with weight loss for 1 month and flu like symptoms for 3 days prior to admission. On day of presentation, she was found to be confused, sleepy and not able to recognize people around her. In ED, patient was confused, GCS 8 severely dehydrated with poor skin turgor and marked delay in capillary refill >3s. Patient was afebrile, with HR 115 bpm, BP 95/60mmHg, and BMI 20kg/m2. Initial labs revealed; severe acidosis pH 6.8, blood glucose (BG) >38 mmol/l and corrected Na 155 mmol/l. Calculated serum osmolality 357mOsm/kg, lactic acid 5 mmol/l and HCO3 3 mmol/l. Further labs revealed K 4.4 mmol/l, Urea 10 mmol/l, Cr 150 micromole/l, WBC 26 and Ketones 3+ in urine. DKA was diagnosed and treated in ED with 4L IVF (2L bolus NaCl and other 2L of 0.23% NaCl given at 15 ml/hr) and NaHCO3 150 mmol. Continuous insulin regular infusion at rate of 0.1U/Kg/hr as per protocol was initiated. Patient was admitted to ICU for close monitoring of BG, GCS and electrolytes. After 9 hours of management, patient GCS improved to 13-14. Repeated labs revealed; improvement in PH 7.17, BG 22mmol/l, HCO3 5 mmol/l and lactic acid 1 mmol/l. There was worsening of Na 159 mmol/l and K dropped to 2.6 mmol/l. IV KCL bolus 20mmol followed by 40mmol IV continuous in IVF was initiated. IVF was changed from NaCl to D5W at 125ml/hr. Electrolytes were repeated after 7 hours and showed improvement in and Na and k levels. During her stay in ICU, patient recovered to baseline GCS 15 with no residual symptoms. IV insulin infusion was stopped on 3(rd) day and commenced on Insulin glargine and insulin Aspart boluses. Further investigations confirmed DM type 1; HbA1c 15%, C-peptide 0.08 nmol/l, IA2Ab of >400 and GAD Ab >250. Patient had an uneventful hospital course, she stayed in ICU for 3 days and then shifted to medical floor. She was discharged on basal bolus insulin regimen. In patients with uncontrolled DM/DKA, serum Na level is variable, reflecting the balance between the hyperglycaemia induced water movement out of the cells that lowers serum Na level, and the glycosuria induced osmotic diuresis, which tends to raise serum Na. When there is marked osmotic diuresis, DKA may present with a normal or even elevated serum Na concentration, despite a markedly elevated serum BG. To best of our knowledge, this is the second case to report an unusual DKA presenting with hypernatremia in adult patient.