Endocrine Abstracts

A 68-year-old lady was admitted with constipation, epigastric pain, vomiting, occasional coffee ground emesis and melena. She had no chest pain, osmotic symptoms or weight changes. Past medical history was significant for peptic ulcer disease and she was not taking any medications apart from over the counter cod liver oil. She did not have diabetes or cardiovascular risk factors. Her sister had type 1 diabetes. Examination was remarkable for dehydration, mild tachycardia and melena on rectal examination. Blood tests including haemoglobin, clotting, renal function, electrolytes were normal. Glucose was 37 mmol/l, ketones were 4.3 mmol/l and there was mild acidosis. She was treated with intravenous fluids, intravenous insulin, proton pump inhibitors and anti-emetics. Electrocardiogram (ECG) showed deep T wave inversions in infero-lateral leads. Cardiac enzymes repeated many times were normal, chest X-ray was normal and echocardiogram revealed normal left ventricular function. ECG changes resolved in 24 h. She was diagnosed to have diabetes with high glycated haemoglobin, negative diabetes auto-antibodies and raised C-peptide level, and was commenced on subcutaneous insulin and metformin. Oesophago-gastro-doudenoscopy suggested mild gastritis. ECG changes in diabetic ketoacidosis (DKA) usually signify cardiac ischaemia or electrolyte abnormalities. Abnormal ECG in absence of the above causes in patients with DKA is reported in literature and has been termed as ‘pseudoinfarction’. The ECG changes may include ST-segment elevation or depression, T-wave changes and can be non-specific. It is postulated that the acidosis causes change in myocyte cell membrane permeability leading to electrolyte shifts across the membrane with resultant abnormalities in electrocardiogram. The abnormalities tend to resolve with the resolution of acidosis. All patients with DKA and chest pain or ECG changes should have standard assessment with cardiac biomarkers, electrocardiographic monitoring, if appropriate, echocardiogram and coronary angiogram. Cardiology consult should be obtained in suspicious cases but clinicians should be mindful that ECG abnormalities in DKA are not always sinister.