Abstract
Background: Diabetes Mellitus type 2 and Glucose 6 Phosphate Dehydrogenase (G6PD) Deficiency are two of the more common diseases worldwide. However, there are only a few reported cases wherein Diabetic Ketoacidosis (DKA) unmasks underlying undiagnosed G6PD. Clinical Case: This is a case of a 25-year-old Filipino male, with no known comorbidities, who came in due to sudden onset of severe epigastric pain after an alcoholic binge. On admission, he was noted to be dehydrated and drowsy, with Kussmaul’s breathing. Upon work-up, capillary blood glucose was elevated at 395mg/dL, ketonemia at 3.7mmol/L (n <0.6mmol/L) and high anion gap (27) metabolic acidosis on arterial blood gas (pH 6.85 n7.35-7.45, pCO2 10mmHg n 35-45mmHg, HCO3 1.7mmol/L n22-26mmol/L); case was diagnosed as Severe DKA. The patient was managed accordingly, primarily with aggressive hydration, intravenous insulin therapy and sodium bicarbonate. He was immediately intubated and ventilated mechanically for respiratory support. On the third hospital day, there was improvement and eventual correction of hyperglycemia and acidosis with transition of management to subcutaneous insulin. However, he was noted to have jaundice and reddish discoloration of urine. Tests showed positive for hemoglobinuria, with concomitant decrease in hemoglobin at 6.6 g/dL from a baseline of 14.9 g/dL (n 12.3-15.3g/dL). Further work-up revealed bilirubinemia (total bilirubin 5.34mg/dL n 0.2-1.2mg/dL, direct bilirubin 4.26mg/dL n 0-0.5mg/dL), elevated LDH (955.57 U/L n 125-220U/L) and high immature reticulocyte fraction of 14.2% (n <5.3%) which points to a diagnosis of hemolytic anemia. Malarial smear, direct and indirect Coomb’s test and hemoglobin electrophoresis for thalassemia, done to investigate the etiology of hemolytic anemia, were all negative. CT scan of the whole abdomen showed splenomegaly (13.8 x 3.9 x 11.3cm). Upon review, there was positive family history of G6PD deficiency. Assay for G6PD was done and revealed less than 60%, confirming the diagnosis. Serial CBC monitoring was requested and transfusion of packed RBC was done as needed. On the 16th day of admission, he was discharged stable on insulin basal-bolus regimen. Conclusion: Although a rare complication, hemolytic anemia in patients with DKA should prompt clinicians to suspect concomitant diagnosis of G6PD deficiency.