Endocrine Abstracts

We describe the case of a 77 year old male admitted with acute confusion. He had a background of Type 2 Diabetes Mellitus, alcohol excess, hypertension, and was a heavy smoker. A venous blood gas showed a high anion gap metabolic acidosis (pH 7.327, a modestly elevated lactate at 1.3), a glucose level of > 27.8 mmol/l, with a capillary ketone level of 5.0 mmol/l. His calculated serum osmolality was 276 mmol/kg, although account was not taken of the possibility of concomitant alcohol intoxication which might have led to a higher calculated osmolality. Unfortunately, a measured serum osmolality was not included in the initial blood tests in the emergency department. He was approaching diabetic ketoacidosis, and was likely in a hyperosmolar hyperglycaemic state. A fixed rate insulin infusion was started. Biochemical parameters improved within hours of initiating Insulin, and were accompanied by improvement in symptoms. A urinary tract infection, manifested by urinary retention, was treated. Subsequent history taking revealed significant weight loss and epigastric discomfort in the context of a new Iron Deficiency Anemia. CT imaging revealed a 5.2 cm mass in the tail of the pancreas. CA 19–9 level was 5855 kU/l. His diabetes was reasonably controlled with an HbA1c of 57 mmol/mol one year before admission. Subsequent months saw an alarming rise in his HbA1c, reaching a level of 146 mmol/mol one month prior to admission. Non-compliance was suspected. In our patient the precipitant of HHS may have been a urinary tract infection. He had two well-established risk factors for pancreatic cancer, namely, smoking and Type 2 Diabetes. There are conflicting data regarding the significance of alcohol as a risk factor for pancreatic cancer. Two pooled analyses suggested that, if there is an effect of alcohol, it is small and limited to heavy drinkers. There are suggestions that Diabetes may be a consequence rather than a cause of pancreatic cancer. A recent onset of Diabetes may be an indicator of underlying pancreatic cancer or herald its onset. Here, rapidly worsening glycaemic control, culminating in HHS may have been a harbinger of the pancreatic cancer diagnosis. It is unfeasible to screen every older asymptomatic adult with new onset Diabetes or unexplained deterioration in glycaemic control with cross-sectional imaging. However, healthcare professionals must be alert to the possibility of an underlying pancreatic cancer given its poor prognosis at all stages, especially when there are risk factors and symptoms.