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Diabetes and rapidly advancing pneumonia
  1. A Bhansalia,
  2. V Suresha,
  3. D Chaudhryb,
  4. K Vaipheic,
  5. R J Dasha,
  6. N Kotwala
  1. aPostgraduate Institute of Medical Education and Research, Chandigarh, India: Department of Endocrinology, bDepartment of Pulmonary Medicine, cDepartment of Pathology
  1. Professor R J Dash, Department of Endocrinology, PGIMER, Chandigarh 160012, Indiarjdash{at}rediffmail.com

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Answers on p 740.

A 20 year man, who was known to have had type 1 diabetes for the past one year, had high grade fever with chills and rigors, and cough with expectoration for 15 days. He was admitted with epigastric pain, vomiting, and tachypnoea after not taking insulin for four days before admission.

On examination, he was moderately dehydrated but well oriented. His pulse was 120 beats/min regular, blood pressure 110/70 mm Hg, and he was febrile. His chest revealed fine crepitations in the left interscapular region. Other systemic examination was normal.

On investigation, his spot capillary blood glucose was 24.3 mmol/l, pH 7.25, bicarbonate 4 mmol/l, anion gap of 37 mmo1/l, arterial oxygen pressure 13.3 kPa, and arterial carbon dioxide pressure 1.2 kPa. Urine ketones were strongly positive (4+). His serum sodium concentration was 134 mmol/l, potassium 3.8 mmol/l, urea 10.5 mmol/l, and creatinine 45 μmol/l. Haematology investigations showed a haemoglobin of 101 g/l, total leucocyte count 18.9 × 106 /l with 81% polymorphs. Chest radiography showed left mid and lower zone infiltrates. Blood and sputum cultures were sterile. He received intravenous saline, appropriate insulin infusion with potassium supplementation, amoxycillin-clavulanic acid, amikacin, and metronidazole. He recovered from ketoacidosis within 24 hours and the pH went up to 7.47, arterial oxygen pressure was 13.10 kPa, arterial carbon dioxide pressure 2.27 kPa, bicarbonate 13 mmol/l with saturation of 98%. However, his fever did not abate. His arterial oxygen pressure and oxygen saturation dropped to 6.93 kPa and 90% respectively. The arterial oxygen pressure/fractional inspiratory oxygen ratio was <150 mm Hg suggestive of acute respiratory distress syndrome (ARDS). His chest radiograph revealed bilateral pulmonary infiltrates, left more than right (fig 1). He was put on assisted ventilation and the antibiotics were changed to ceftizidime, netilmycin, cloxacillin, and metronidazole. Subsequently, he had an upper gastrointestinal bleed, which was managed with blood transfusion and intravenous ranitidine. He remained hypoxic despite an inverse ratio ventilation and developed respiratory acidosis. The lung lesion did not respond to the treatment and he died of his illness. Postmortem lung biopsy was done.

Figure 1

Chest radiograph of the patient showing bilateral pneumonia.

Questions

(1)
What are the possible diagnoses and how would you investigate this patient?
(2)
How would you manage the condition?

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