scholarly journals Fulminant Diabetes in a Patient with Advanced Melanoma on Nivolumab

2018 ◽  
Vol 2018 ◽  
pp. 1-4 ◽  
Author(s):  
Nora Chokr ◽  
Hafsa Farooq ◽  
Elizabeth Guadalupe
Keyword(s):  
Blood Glucose ◽  
Pancreatic Beta Cells ◽  
Islet Cell Antibodies ◽  
Advanced Melanoma ◽  
Acid Decarboxylase ◽  
High Dose ◽  
Arterial Blood ◽  
History Of ◽  
Fulminant Diabetes ◽  
Beta Hydroxybutyrate

Background. Anti-PD-1 agents were approved for advanced melanoma after the landmark trial Checkmate-037. Anti-PD-1 agents can breach immunologic tolerance. Fulminant diabetes is an immune endocrinopathy that results from a violent immune attack leading to complete destruction of pancreatic beta cells in genetically predisposed people. We present a rare case of fulminant diabetes precipitated by anti-PD-1 immunotherapy.Case. A 61-year-old male with advanced melanoma presented with a three-day history of nausea, vomiting, and malaise. He was started on nivolumab and ipilimumab. After the third dose, he developed a generalized rash and was prescribed high-dose prednisone. Labs revealed potassium 9.5 mmol/L, sodium 127 mmol/L, bicarbonate <10 mmol/L, blood glucose 1211 mg/dL, anion gap >31 mmol, arterial blood pH 7.14, and beta-hydroxybutyrate 13.7 mmol/L. He was diagnosed with diabetic ketoacidosis. Hemoglobin A1C was 6.9%. C-peptide was undetectable (<0.1 ng/ml). Glutamic acid decarboxylase autoantibodies, zinc transporter 8 autoantibodies, insulin autoantibodies, islet antigen 2 autoantibodies, and islet cell antibodies were all negative.Conclusion. Anti-PD-1 immunotherapy is effective in cancers refractory to standard chemotherapy. These agents can precipitate autoimmune disorders. As the use of anti-PD-1 agents is expected to rise, physicians should be educated about the potential side effects. We recommend conducting routine blood glucose checks in patients on these agents.

Nivolumab-induced type 1 diabetes mellitus as an immune-related adverse event

2019 ◽  
Vol 26 (1) ◽  
pp. 236-239 ◽  
Author(s):  
Mesut Yilmaz
Keyword(s):  
Immune Checkpoint ◽  
Pancreatic Beta Cells ◽  
Checkpoint Inhibitors ◽  
Islet Cell Antibodies ◽  
Retroperitoneal Lymph Node Dissection ◽  
Acid Decarboxylase ◽  
Family History Of Diabetes ◽  
Arterial Blood ◽  
History Of ◽  
Fulminant Diabetes

Background Immune checkpoint inhibitors are medications that activate anti-tumor responses by disrupting the inhibitory signaling to T cells. Nivolumab is an immune checkpoint inhibitor that selectively blocks the programmed cell death-1 (PD-1). Anti-PD-1 agents can breach immunologic tolerance. Fulminant diabetes is an immune endocrinopathy that results from a violent immune attack leading to complete destruction of pancreatic beta cells. We present a rare case of fulminant diabetes precipitated by anti-PD-1 immunotherapy. Case A 49-year-old male with a body mass index of 26.4 kg/m2, a history of Dandy–Walker syndrome and epilepsy, and no personal or family history of diabetes underwent left radical nephrectomy and retroperitoneal lymph node dissection for stage IV metastatic renal cell carcinoma (metastases to lungs). He received first-line sunitinib treatment for three months. He developed new hepatic metastasis, and a second-line treatment with nivolumab 3 mg/kg every two weeks was introduced. At 10 months of nivolumab, before the 22nd infusion, the patient suddenly complained of severe asthenia, somnolence, weight loss, polydipsia, and polyuria. Laboratory tests revealed potassium 4.2 mmol/L, sodium 138 mmol/L, bicarbonate 17.8 mmol/L, blood glucose 801 mg/dL, and arterial blood pH 7.27. He was diagnosed with diabetic ketoacidosis. Hemoglobin A1C was 10.9%. C-peptide was so low as 0.24. Glutamic acid decarboxylase autoantibodies, insulin autoantibodies and islet cell antibodies were all negative. Conclusion Anti-PD-1 immunotherapy is effective in the treatment of cancers. These agents can precipitate autoimmune disorders. As the use of anti-PD-1 agents is expected to rise, physicians should be educated about the potential side effects.

scholarly journals Blood Glucose Changes during Neurosurgery

1979 ◽  
Vol 7 (1) ◽  
pp. 45-49
Author(s):  
Christopher G. Male
Keyword(s):  
Blood Glucose ◽  
Family History ◽  
Body Temperature ◽  
Older Patients ◽  
High Dose ◽  
Family History Of Diabetes ◽  
Induced Hypotension ◽  
Glucose Levels ◽  
Blood Glucose Levels ◽  
History Of

Blood glucose levels were studied prospectively in 40 patients undergoing elective major craniotomy. A significant (p < 0.01) hyperglycaemic response was noted after scalp infiltration with adrenaline and incision (0.5 mmol/l) and with continued surgery (0.9 mmol/l). Patients aged 50 years and under showed a significantly greater rise with adrenaline and incision than older patients (0.8 compared with 0.4 mmol/l p < 0.01). Preoperative high dose steroid therapy did not modify the response Blood glucose changes were unrelated to sex, obesity, a family history of diabetes, the duration of starvation, intraoperative body temperature, anaesthetic technique induced hypotension or blood loss.

scholarly journals DIABETIC KETOACIDOSIS WITH LOWER-THAN-ANTICIPATED GLUCOSE LEVELS WITH SGLT-2 INHIBITOR CANAGLIFLOZIN: A CASE REPORT AND REVIEW OF THE LITERATURE.

2020 ◽  
pp. 1-2
Author(s):  
Ajay Budhwar ◽  
Parul Malhotra
Keyword(s):  
Case Report ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Sglt2 Inhibitor ◽  
Gas Analysis ◽  
Glucose Levels ◽  
Arterial Blood ◽  
History Of ◽  
Euglycemic Diabetic Ketoacidosis

We describe a case report of a patient who presented with euglycemic diabetic ketoacidosis (euDKA), six days after starting treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitor, Canagliflozin. ‘Euglycemic diabetic ketoacidosis’ or ‘DKA with lower-than-anticipated glucose levels’ (as recommended by AACE/ACE) is a rare, challenging and easy to miss the diagnosis A 41-year-old male with a history of type 2 Diabetes Mellitus presented with uncontrolled hyperglycemia. Canagliflozin (SGLT2 inhibitor) was added to his anti-diabetic regimen of Metformin and Sitagliptin. Six days later, he presented with symptoms of diabetic ketoacidosis with normal blood glucose of 131mg/dl. The patient was further investigated with arterial blood gas analysis and serum ketone studies, keeping in view of the potential of euglycemic diabetic ketoacidosis (euDKA) with SGLT2 inhibitor use. The clinical picture and lab values of the patient were consistent with diabetic ketoacidosis(DKA), although it is rare in type 2 DM. Blood glucose was in the normal range which could have delayed the diagnosis if the physician was not vigilant. If one had only focused on the blood glucose, then this potentially fatal condition could have been missed. However, when other causes of anion gap metabolic acidosis were excluded and the lab values of urine ketones, elevated beta-hydroxybutyrate, reduced bicarbonate, and normal lactate interpreted, it leads to the diagnosis of SGLT2 inhibitor-associated euglycemic DKA. We performed a literature review of this topic and discuss the history of euglycemic diabetic ketoacidosis, risk factors, pathophysiology, diagnosis, management, and prevention of SGLT2 inhibitor-induced euDKA.

scholarly journals Covid-19 and New Onset Diabetes: A Case Series

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A338-A339
Author(s):  
Marwa Saleem ◽  
Tasneem Zahra ◽  
Vidya Menon ◽  
Julia Vargas-Jerez ◽  
Amara Sarwal
Keyword(s):  
Case Series ◽  
Islet Cell Antibodies ◽  
Insulin Requirement ◽  
Serum Glucose ◽  
Acid Decarboxylase ◽  
Igg Antibody ◽  
History Of ◽  
Diagnosed Diabetes ◽  
New Onset

Abstract Background: During the SARS CoV1 pandemic in 2003, there was much literature published about newly diagnosed diabetes mellitus (DM) in the patient population infected. This phenomenon has not been well established during this SARS CoV2 pandemic. In this case series, we aim to evaluate patients admitted to our facility with new onset DM who had a history of COVID-19 infection. Method: This was a single center case series that included adult patients who presented to our facility with new onset DM during June-October 2020 who had a history of SARS CoV2 positive PCR and/or positive IgG antibody to SARS CoV2. Pregnant patients were excluded. Data was collected from the hospital electronic medical records. Diagnosis of diabetes was determined in these patients via hemoglobin A1C (HbA1C) level greater than 6.5%. Results: Six patients fulfilled our diagnostic criteria. All patients were male with a median age of 54 years. The median BMI is 33.9, with 5 patients considered to be obese and 1 overweight. Other than the increased BMI, 2 patients with pre-DM and 3 patients who had a family history of DM, no other identifiable risk factors for DM were noted in this cohort. Five patients required hospitalization for HHS or DKA and 1 patient was managed as an outpatient. Median random serum glucose on presentation was 761.5 mg/dl and median HbA1C on presentation was 11.5%. Significant dosages of parenteral insulin (0.45 U/Kg) was required for hospitalized patients during their inpatient stay along with immediately after discharge to control their hyperglycemia. Glutamic Acid Decarboxylase and Islet Cell antibodies were done for 2 of the patients and were negative. Three of the patients who had follow up in 2 months showed improvement in their HbA1C (median of 7.1% [5.4–10.7]) and considerably diminished subcutaneous insulin requirement (0.2U/Kg). Two of these patients continued to follow up, and at 4 months from onset of DM, median HbA1C was 5.85% with insulin ceased. Of note, the patient who was lost to follow up was found to have an HbA1C improvement from 11.4% to 5.4% at the 2 month mark. Discussion: Both SARS CoV1 and SARS CoV2 activates the RAAS, causing insulin resistance by altering insulin signaling and increasing oxidative stress leading to dysfunction of pancreatic beta calls. The inflammatory cytokine storm response seen in COVID-19 can also decrease skeletal muscle sensitivity to insulin and decrease peripheral glucose uptake. These mechanisms may be leading to the new-onset DM noticed in our COVID-19 patients. In addition, there may be a possible immune-mediated mechanism given the matched time line between the COVID-19 antibody life span and the duration of DM. It is unknown whether this effect is permanent or temporary, although our results do support the latter. More studies that utilize a larger cohort and longer follow up are needed in order to get a better understanding of the mechanism of DM in COVID-19 infection.

ITI with high-dose FIX and combined immunosuppressive therapy in a patient with severe haemophilia B and inhibitor

2009 ◽  
Vol 29 (02) ◽  
pp. 155-157 ◽  
Author(s):  
H. Hauch ◽  
J. Rischewski ◽  
U. Kordes ◽  
J. Schneppenheim ◽  
R. Schneppenheim ◽  
...  
Keyword(s):  
Nephrotic Syndrome ◽  
Immunosuppressive Agents ◽  
Tolerance Induction ◽  
Intravenous Immunoglobulins ◽  
Factor Ix ◽  
High Dose ◽  
Allergic Reactions ◽  
Success Rates ◽  
Serious Infections ◽  
History Of

SummaryInhibitor development is a rare but serious event in hemophilia B patients. Management is hampered by the frequent occurrence of allergic reactions to factor IX, low success rates of current inhibitor elimination protocols and the risk of development of nephrotic syndrome. Single cases of immune tolerance induction (ITI) including immunosuppressive agents like mycophenolat mofetil (MMF) or rituximab have been reported. We present a case of successful inhibitor elimination with a combined immune-modulating therapy and high-dose factor IX (FIX). This boy had developed a FIX inhibitor at the age of 5 years and had a history of allergic reactions to FIX and to FEIBA→. Under on-demand treatment with recombinant activated FVII the inhibitor became undetectable but the boy suffered from multiple joint and muscle bleeds. At the age of 11.5 years ITI was attempted with a combination of rituximab, MMF, dexamethasone, intravenous immunoglobulins and high-dose FIX. The inhibitor did not reappear and FIX half-life normalized. No allergic reaction, no signs of nephrotic syndrome and no serious infections were observed.

Study of Diabetic Mellitus and Knowledge of Lotion Foot Care on the Community

2018 ◽  
Vol 9 (3) ◽  
Author(s):  
Hariyadi DM ◽  
Athiyah U ◽  
Hendradi E ◽  
Rosita N ◽  
Erawati T ◽  
...  
Keyword(s):  
Blood Glucose ◽  
T Test ◽  
Small Scale ◽  
Scale Production ◽  
Foot Care ◽  
Diabetic Mellitus ◽  
Glucose Levels ◽  
Blood Glucose Levels ◽  
Before And After ◽  
History Of

The prevention of Diabetic Mellitus (DM) and its complications is the main aim of this study, in addition to the training of lotion foot care application and the development of small scale industry. The research team delivered knowledge in the form of training on Diabetic Mellitus, healthy food, treatment and prevention of complications, and small-scale production of cosmetic products. The aim of this study was to determine the correlation between training on diabetic and lotion foot care application as preventive measures against diabetic complications on the patient's blood glucose levels in the community of residents in Banyuurip Jaya, Surabaya. It was expected from this training that the knowledge of the residents increases and people living with diabetic undergo lifestyle changes and therefore blood sugar levels can be controlled. The parameters measured in this research were blood glucose levels, the anti diabetic drug types consumed, and compliance on diabetics. This study used the data taken from 60 patients with DM over a period of one month. Questionnaires and log books was used to retrieve data and changes in blood glucose levels in diabetic patients. The results showed the demographic data of patients with type 2 diabetic of 85% female and 15% male, with the range of patients aged of 61-70 years of 46.67% and had history of diabetic (90%). The history of drugs consumed by respondents was anti diabetic drugs such as metformin (40%), glimepiride (33.37%) and insulin (6.67%). In addition, the increased knowledge of DM patients after being given the training compared to before training was shown in several questions in the questionnaire. A statistical analysis using t-test analyzed a correlation between training provided in order to enhance understanding of the patient, as well as correlation with blood glucose levels. A paired T-test showed that there was a relationship between the knowledge of trainees before and after training (p less than 0.05). An interesting result was that there was no relationship between blood glucose levels before and after training provided (p> 0.05).

Glucose Levels and Outcome After Primary Intraventricular Hemorrhage

2019 ◽  
Vol 16 (1) ◽  
pp. 40-46
Author(s):  
Rui Guo ◽  
Ruiqi Chen ◽  
Chao You ◽  
Lu Ma ◽  
Hao Li ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Blood Glucose ◽  
Blood Glucose Level ◽  
Incidence Rate ◽  
Glucose Level ◽  
Intraventricular Hemorrhage ◽  
Laboratory Data ◽  
History Of ◽  
Poor Outcomes ◽  
The Impact

Background and Purpose: Hyperglycemia is reported to be associated with poor outcome in patients with spontaneous Intracerebral Hemorrhage (ICH), but the association between blood glucose level and outcomes in Primary Intraventricular Hemorrhage (PIVH) remains unclear. We sought to identify the parameters associated with admission hyperglycemia and analyze the impact of hyperglycemia on clinical outcome in patients with PIVH. Methods: Patients admitted to Department of Neurosurgery, West China Hospital with PIVH between 2010 and 2016 were retrospectively included in our study. Clinical, radiographic, and laboratory data were collected. Univariate and multivariate logistic regression analyses were used to identify independent predictors of poor outcomes. Results: One hundred and seventy patients were included in the analysis. Mean admission blood glucose level was 7.78±2.73 mmol/L and 10 patients (5.9%) had a history of diabetes mellitus. History of diabetes mellitus (P = 0.01; Odds Ratio [OR], 9.10; 95% Confidence Interval [CI], 1.64 to 50.54) was independent predictor of admission critical hyperglycemia defined at 8.17 mmol/L. Patients with admission critical hyperglycemia poorer outcome at discharge (P < 0.001) and 90 days (P < 0.001). After adjustment, admission blood glucose was significantly associated with discharge (P = 0.01; OR, 1.30; 95% CI, 1.06 to 1.59) and 90-day poor outcomes (P = 0.03; OR, 1.27; 95% CI, 1.03 to 1.58), as well as mortality at 90 days (P = 0.005; OR, 1.41; 95% CI, 1.11 to 1.78). In addition, admission critical hyperglycemia showed significantly increased the incidence rate of pneumonia in PIVH (P = 0.02; OR, 6.04; 95% CI 1.27 to 28.80) even after adjusting for the confounders. Conclusion: Admission blood glucose after PIVH is associated with discharge and 90-day poor outcomes, as well as mortality at 90 days. Admission hyperglycemia significantly increases the incidence rate of pneumonia in PIVH.

Pseudo-Parkinson Disease Secondary to Ritonavir–Buspirone Interaction

2003 ◽  
Vol 37 (2) ◽  
pp. 202-205 ◽  
Author(s):  
Patrick G Clay ◽  
Molly M Adams
Keyword(s):  
Drug Interaction ◽  
Inhibitory Effect ◽  
Hiv Positive ◽  
High Dose ◽  
Resting Tremor ◽  
Case Summary ◽  
History Of ◽  
Drug Drug Interaction ◽  
To Receive

OBJECTIVE: To report a case of Parkinson-like symptoms appearing in a patient after introduction of ritonavir to buspirone therapy. CASE SUMMARY: A 54-year-old HIV-positive white man presented to the clinic with a 2-week history of ataxia, shuffling gait, cogwheel rigidity, resting tremor, and sad affect with masked features. This patient had been receiving high-dose buspirone (40 mg every morning and 30 mg every evening) for 2 years prior to the introduction of ritonavir/indinavir combination therapy (400 mg/400 mg twice daily) 6 weeks prior to initiation of the above symptoms. Buspirone was decreased to 15 mg 3 times daily, ritonavir/indinavir was discontinued, and amprenavir 1200 mg twice daily was added. The patient's symptoms began to subside after 1 week, with complete resolution after about 2 weeks. The patient continued to receive buspirone for an additional 12 months without recurrence of symptoms. DISCUSSION: This is the first reported interaction of buspirone and antiretrovirals. Buspirone, extensively metabolized by CYP3A4, was likely at supratherapeutic levels due to the inhibitory effect of ritonavir and, secondarily, indinavir. The Parkinson-like symptoms developed rapidly and severely, impacted this patient's quality of life, and necessitated significant clinic expenditures to identify this drug–drug interaction. CONCLUSIONS: This case demonstrates a severe drug–drug interaction between buspirone and ritonavir and further demonstrates the need for awareness of the metabolic profile for all agents an HIV-infected patient is receiving.

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