2465-PUB: Successful Management of Severe Diabetic Ketoacidosis in a Type 2 Diabetes Patient with Insulin Allergy

Objective: To report an episode of severe diabetic ketoacidosis (DKA) in a type 2 diabetes mellitus (DM) patient with insulin allergy treated by continuous intravenous (IV) regular insulin infusion. Methods: We describe the clinical features, laboratory data, and management of severe DKA in a type 2 DM patient with insulin allergy. Results: A 58-year-old man with type 2 DM initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic therapies. Symptoms of an allergic reaction then developed, especially distinct at the injection site. Pruritic wheals appeared within 10 minutes of injection and lasted over 24 hours. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms, and then experienced weakness and upper abdominal pain. On admission, his heart rate was 130 beats/min, temperature 37°C, blood pressure 150/90 mmHg, and respiratory rate 28 breaths/min. Blood glucose level was 374.6 mg/dL, pH 6.984, bicarbonate 2.5 mmol/L, lactate 1.5 mmol/L, BUN 24.1 mg/dL, creatinine 1.46 mg/dL, and urinary ketone was 66.48 mg/dL. Over 24 hours, the metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as hemodialysis. Ultimately, he received continuous IV regular insulin infusion at an initial rate of 0.1 units/kg/hour, no further allergic reactions were observed. On the day 5, ketonemia and metabolic acidosis completely resolved. He had transition from IV insulin infusion to SIA on day 14. He was discharged on the day 21 with the treatment of SIA. Three months later, he had a good glycemic control, but has still appeared allergic symptoms at the injection sites of insulin. Conclusion: In this patient, SIA caused an allergic reaction in contrast to continuous IV insulin infusion, for which allergic symptoms did not appear. Thus, identical insulin molecules could behave in markedly different ways depending on the route of injection. Disclosure A.D. Nguyen: None. C.Q. Luong: None. H.C. Chu: None. V.K. Nguyen: None. C.V. Nguyen: None. T.A. Nguyen: None. Q.H. Nguyen: None. T.D. Mai: None. D.V. Nguyen: None. B.Q. Nguyen: None. T.H. Tran: None. N.N. Nguyen: None. S.N. Do: None.