A vicious cycle of diabetic ketoacidosis and hypertriglyceridemiainduced acute pancreatitis: a case report

Hypertriglyceridemiainduced acute pancreatitis is an uncommon but severe complication of diabetic ketoacidosis (DKA). This case report underscores the interrelated and complex nature of DKA, hypertriglyceridemia (HTG), and acute pancreatitis (AP). A 30-year-old man with obesity and dyslipidaemia, but no prior history of diabetes, presented with severe abdominal pain, vomiting, polyuria, and polydipsia. Initial investigations revealed severe DKA, extreme hypertriglyceridemia with a level of 7068 mg/dL and acute pancreatitis with radiological evidence of pancreatic necrosis. He was managed with ventilatory support, aggressive fluid resuscitation, continuous insulin infusion, and therapeutic plasma exchange (TPE), resulting in significant triglyceride reduction and improved metabolic control. DKA is characterised by insulin deficiency, which leads to hyperglycaemia, ketosis, and metabolic acidosis. Insufficient insulin causes uncontrolled lipolysis, releasing free fatty acids. These are processed in the liver into ketone bodies and very low-density lipoproteins, exacerbating hypertriglyceridemia by reducing lipoprotein lipase activity. Excess chylomicrons in the blood can cause capillary plugging and pancreatic ischemia, activating pancreatic lipase. Insulin therapy is essential for controlling hypertriglyceridemia, while TPE serves as an effective intervention in severe cases, rapidly reducing triglyceride levels and mitigating pancreatitis risk. This case highlights the profound metabolic disturbances associated with uncontrolled diabetes and the intricate interplay between DKA and hypertriglyceridemia, emphasising the importance of prompt and aggressive management.