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Diagnosis and Treatment > Medication

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Sebastian Hörber Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany
Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
German Center for Diabetes Research (DZD), München-Neuherberg, Germany

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Sarah Hudak Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany

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Martin Kächele Department of Internal Medicine, Medical Intensive Care Unit, University of Tübingen, Tübingen, Germany

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Dietrich Overkamp Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany

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Andreas Fritsche Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany
Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
German Center for Diabetes Research (DZD), München-Neuherberg, Germany

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Hans-Ulrich Häring Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany
Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
German Center for Diabetes Research (DZD), München-Neuherberg, Germany

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Andreas Peter Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany
Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
German Center for Diabetes Research (DZD), München-Neuherberg, Germany

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Martin Heni Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Tübingen, Germany
Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
German Center for Diabetes Research (DZD), München-Neuherberg, Germany

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Summary

Diabetic ketoacidosis is a life-threatening complication of diabetes mellitus. It usually occurs in patients with type 1 diabetes where it is typically associated with only moderately increased blood glucose. Here, we report the case of a 52-year-old female patient who was admitted to the emergency unit with severely altered mental status but stable vital signs. Laboratory results on admission revealed very high blood glucose (1687 mg/dL/93.6 mmol/L) and severe acidosis (pH <7) with proof of ketone bodies in serum and urine. Past history revealed a paranoid schizophrenia diagnosed 10 years ago and for which the patient was treated with risperidone for many years. Acute treatment with intravenous fluids, intravenous insulin infusion and sodium bicarbonate improved the symptoms. Further laboratory investigations confirmed diagnosis of autoimmune type 1 diabetes. After normalization of blood glucose levels, the patient could soon be discharged with a subcutaneous insulin therapy.

Learning points:

  • Diabetic ketoacidosis as first manifestation of type 1 diabetes can occur with markedly elevated blood glucose concentrations in elder patients.

  • Atypical antipsychotics are associated with hyperglycemia and an increased risk of new-onset diabetes.

  • First report of risperidone-associated diabetic ketoacidosis in new-onset type 1 diabetes.

  • Patients treated with atypical antipsychotics require special care and regular laboratory examinations to detect hyperglycemia and diabetic ketoacidosis.

  • In cases when the diagnosis is in doubt, blood gas analysis as well as determination of C-peptide and islet autoantibodies can help to establish the definite diabetes type.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Diabetes, Hormone, Insulin, Condition/ Syndrome, Diabetes mellitus type 1, Diabetic ketoacidosis, Hyperglycaemia, Patient Demographics, Age, Adult, Gender, Female, Ethnicity, White, Country of Treatment, Germany, Diagnosis and Treatment, Signs and Symptoms, Abdominal pain, Agitation, Diabetes mellitus type 1, Diabetic ketoacidosis, Hyperglycaemia, Hyperventilation, Nausea, Somnolence, Tachycardia, Vomiting, Investigation, Anion gap, Beta-hydroxybutyrate, Bicarbonate, Chloride, Cortisol, C-peptide (blood), Creatinine, Estimated glomerular filtration rate, GADA, Glucose (blood), Glucose (urine), Haemoglobin A1c, Ketones (urine), Lactate, LDL cholesterol, Lipase (serum), Phosphate (serum), Potassium, Serum osmolality, Sodium, Urea and electrolytes, White blood cell count, Intervention, Fluid repletion, Medication, Benzodiazepines, Diazepam, Insulin, Risperidone, Sodium bicarbonate, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-18-0094
Volume/Issue:
Volume 2018: Issue 1
Open access
Carlos Tavares Bello Endocrinology Department, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal

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Emma van der Poest Clement Faculty of Medicine, Erasmus University, Rotterdam, The Netherlands

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Richard Feelders Endocrinology Department, Erasmus MC, Rotterdam, The Netherlands

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Summary

Cushing’s syndrome is a rare disease that results from prolonged exposure to supraphysiological levels of glucocorticoids. Severe and rapidly progressive cases are often, but not exclusively, attributable to ectopic ACTH secretion. Extreme hypercortisolism usually has florid metabolic consequences and is associated with an increased infectious and thrombotic risk. The authors report on a case of a 51-year-old male that presented with severe Cushing’s syndrome secondary to an ACTH-secreting pituitary macroadenoma, whose diagnostic workup was affected by concurrent subclinical multifocal pulmonary infectious nodules. The case is noteworthy for the atypically severe presentation of Cushing’s disease, and it should remind the clinician of the possible infectious and thrombotic complications associated with Cushing’s syndrome.

Learning points:

  • Severe Cushing’s syndrome is not always caused by ectopic ACTH secretion.

  • Hypercortisolism is a state of immunosuppression, being associated with an increased risk for opportunistic infections.

  • Infectious pulmonary infiltrates may lead to imaging diagnostic dilemmas when investigating a suspected ectopic ACTH secretion.

  • Cushing’s syndrome carries an increased thromboembolic risk that may even persist after successful surgical management.

  • Antibiotic and venous thromboembolism prophylaxis should be considered in every patient with severe Cushing’s syndrome.

Taxonomy:
Clinical Overview, Gland/Organ, Pituitary, Topic, Pituitary, Hormone, ACTH, Cortisol, FSH, IGF1, Insulin, LH, Prolactin, Testosterone, Thyroxine (T4), TSH, Condition/ Syndrome, Cushing's syndrome, Pituitary adenoma, Pneumonia, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Diagnosis and Treatment, Signs and Symptoms, Abdominal adiposity, Chemosis, Diplopia, Facies - moon, Hypercortisolaemia, Hyperglycaemia, Hyperpigmentation, Hypertension, Hypokalaemia, Hypothyroidism, Leukocytosis, Myasthaenia, Peripheral oedema, Psychosis, Ptosis, Thrombocytopenia, Investigation, ACTH, Calcium (serum), Cortisol (9am), Cortisol, free (24-hour urine), C-reactive protein, CT scan, Dexamethasone suppression, FSH, FT4, Glucose (blood, fasting), Haemoglobin, LH, MRI, Platelet count, Potassium, Prolactin, Testosterone, TSH, White blood cell count, Intervention, Adrenalectomy, Radiotherapy, Transsphenoidal surgery, Medication, Amlodipine, Antibiotics, Antipsychotics, Benzodiazepines, Fludrocortisone, Hydrocortisone, Insulin, Levothyroxine, Pantoprazole, Potassium chloride, Spironolactone, Testosterone, Related Disciplines, Oncology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-17-0100
Volume/Issue:
Volume 2017: Issue 1
Open access