A 19 year old Caucasian male presented with nausea and malaise. In the past medical history he had been obese since childhood with hyperphagia and abnormal food seeking behaviour. His father was obese and had type I diabetes mellitus. His mother was also obese and had impaired glucose tolerance.
On examination he was morbidly obese (body mass index 46.9 Kg/M2) and had axillary acanthosis nigracans. He had clinical features of hypovolaemic shock.
Arterial blood gas analysis revealed a metabolic acidosis (pH 7.08 (7.357.45) bicarbonate 13 mmol/l (2228 mmol/l) pCO2 1.37 kPa 4.76.0 kPa)). The urine dipstick was positive for ketones. A diagnosis of DKA was made. The blood glucose was 28 mmol/l.
He was fluid resuscitated and commenced on insulin. He was highly resistant to insulin during the acute illness and resolution of the acidosis required 480 units of insulin per 24 hours (2.96 units/Kg). Following recovery he was hypertensive and blood tests revealed a dyslipidaemic lipid profile. He was discharged on a basal bolus regimen of subcutaneous insulin and metformin.
His islet cell and glutamic acid decarboxylase antibodies were negative. In view of his hyperphagia an MRI of the hypothalamus was performed which did not show a lesion. He is due to have genetic testing to look for a monogenic cause of his obesity.
Type II diabetes, particularly in young obese Afro-Caribbean patients can present with DKA however reports in Caucasian patients in the UK are very rare. The mechanism of the development of temporary absolute insulin deficiency in type II diabetes leading to DKA is not well defined.