Endocrine Abstracts

A 12 year old male presented to the Emergency Department in severe diabetic ketoacidosis (DKA) with a new diagnosis type 1 diabetes mellitus. He had tested positive for Covid a few weeks prior resulting in a reduced appetite and weight loss. He had no other past medical history. He was treated as per the BSPED guideline for DKA and remained on the protocol for 24 hours. He had normal electrolytes on admission but DKA resolution was complicated by hyperchloraemic acidosis, mild hypernatraemia and mild hypokalaemia. Hours after completing his DKA treatment, having commenced subcutaneous insulin and normal oral intake, he developed severe hypokalaemia (2.0 mmol/l) and moderate hypophosphataemia (0.66 mmol/l). Despite electrolyte replacement, both his potassium and phosphate levels kept falling. On review of his history, he was a competitive boxer with regular weigh-ins and over the preceding four weeks his weight had plummeted from 48 kg to 35 kg on admission, a loss of 27% of his body weight. His electrolyte imbalances were secondary to refeeding syndrome in view of his prolonged period of reduced intake followed by a rapid return in his appetite. However, this diagnosis was not considered initially until further history taking was carried out. Fortunately, after 48 hours of ongoing replacement, his electrolytes stabilised with no evidence of organ dysfunction. ASPEN defines Refeeding syndrome as a reduction in phosphorous, potassium and/or magnesium by >10%, and/or organ dysfunction as a result of electrolyte decrease or from thiamine deficiency, occurring within 5 days of the reintroduction of calories (1). This case demonstrates the importance of a thorough history, particularly when a patient’s recovery does not progress as expected. Moreover, it highlights the importance of considering the risk of refeeding syndrome for all children who have not received optimal nutritional support for >3 days (2), a common occurrence in children newly diagnosed with type 1 DM, whether they present in DKA or not. Early recognition facilitates appropriate electrolyte management, controlled refeeding and timely initiation of thiamine supplementation.