The ketosis-prone diabetes diagnosis dilemma-a case report

Results A 16-year-old African American male was brought to emergency with abdominal pain, vomiting, lack of appetite and loss of 13kg (regular weight 152Kg, BMI 42.5kg/m). Evaluation detected dehydration, blood glucose of 550mg/dL, acidosis and ketonemia. There was no previous diagnosis of diabetes. He received management for DKA, with fluid therapy and regular insulin via continuous intravenous infusion (around 100-140UI/ day) for 4 days. Subcutaneous insulin regimen with NPH and regular at meals was initiated after correction of acidosis. He kept capillary glycemia around 250mg/ dL despite increasing doses of insulin and exclusion of other pathologies. Detectable C-peptide (1.32; 0.785.19ng/mL), negative glutamic acid decarboxylase antibodies (anti-GAD), along with laboratory tests done a year ago showing fasting plasma glucose of 117mg/dL and glycated hemoglobin (A1c) of 6.2%, justified starting metformin 850mg/day. Patient evolved with marked improvement of glycemic control and was discharged. He returned at the diabetes clinic after 1 month, bringing his self-monitoring showing capillary blood glucose between 60-130mg/dL and A1c of 9.3%. Insulin was gradually reduced and metformin increased to maximum dose, leading to KPD hypothesis. Patient is currently receiving outpatient treatment and waiting result of HLA assessment.