Endocrine Abstracts

A 63-year-old female presented to Galway University Hospital with a two-week history of vomiting and diarrhoea on a background of poorly controlled type 1 diabetes. She was hypotensive and tachycardic with a GCS of 13/15. Investigations revealed hyperglycaemia and ketonemia with a high anion gap metabolic acidosis. The working diagnosis was diabetic ketoacidosis (DKA) secondary to sepsis of unknown source. She was commenced on a DKA protocol with intravenous antibiotics and steroids and transferred to the high dependency unit for ionotropic support. Despite resolution of her hyperglycaemia and ketonemia, her metabolic acidosis persisted and on day 5 of admission she developed an acute transaminitis with synthetic liver dysfunction requiring vitamin K and fibrinogen replacement. Differential diagnosis was vitamin K deficiency secondary to malnutrition. Gastroscopy showed flattening of the duodenum. Drug reconciliation revealed that she was commenced on Konverge 20 mg/5mg in 2019 which was increased in 2022 to 40 mg/5mg. Considering this, the differential diagnosis was angiotensin II receptor blocker (ARB) induced enteropathy. She was commenced on Rifaximin and Budesonide. Her symptoms gradually improved and she was discharged home on day 33 of admission. She has since completed treatment with Budesonide and remains well. Sprue-like enteropathy associated with angiotensin II receptor blockers was first described in 2012. Although the incidence is not clear, it is thought to be rare. The mechanism of injury is not well established however an immune-mediated disorder is thought to occur in susceptible individuals. Cessation of the ARB results in complete resolution of both clinical and histological features.