Carbohydrate

Metabolism
Case Discussion
• History: 69 year old male, known Diabetic on Treatment
presented to OPD
1. Decreased sensation of sole of feet x 3 months
2. Left lower limb swelling x 15 days with pus
discharge

• Defaulter on medication
• Occasional alcohol intake and bidi smoking
• No significant family history
• No other significant history
General Physical Examination
• Conscious Oriented
• Obese Built
• Afebrile
• Weight: 88 Kg Height: 165 cm BMI: 31kg/𝑚2
• No Pallor/ Clubbing/ Icterus/ Cyanosis/ LAP/ Edema
• HR: 86 bpm
• BP : 138/86 mmHg
Systemic Examination
• CVS, Respiratory system and Abdominal examination: WNL
• CNS : Crude, fine touch & Pressure sensation b/l feet
Proprioception and vibration still retained
Examination:
Local site:
• RBS: 260 mg/dl (spot) [70-140 mg/dL)
• Urine Analysis:
• FBS: 173 mg/dl [70-110 mg/dL]
Glucose : +
• PPBS : 208 mg/dl [70-140 mg/dL]
Ketone : -
• Hba1c : 8.3% [4.0-6.2%]
Leukocytes : -
• TLC : 11600/ cumm [4000-10000 cumm]
Pus cells: -
• DLC: N- 78.5 % L- 18.5% E-01
• M- 0.4% B-02
• S. Na: 135 meq/L [135-145 meq/L]
• S. K : 3.8 meq/L [3.5-5.0 meq/L]
• S. Creatinine : 0.66mg/dL [0.72-1.18 mg/dL]
• S. LDL : 125 mg/dL [<130 mg/dL]
• S. HDL : 35 mg/dL [40-60mg/dL]
• S. Triglycerides : 160 mg/dL [<150 mg/dL]
Final Diagnosis
History : 18 year old apparently healthy woman with h/o
weight loss and fatigue presented to emergency with

1. C/o abdominal pain and vomiting x 2-3 hours

2. State of confusion & disorientation

No other Significant history

General Physical Examination
• Altered sensorium
• Thin Built
• Afebrile
• HR: 118 bmps
• BP : 120/85 mmHg
• No Pallor/ Clubbing/ Icterus/ Cyanosis/ LAP
• Dry oral mucosa
Systemic Examination
• CVS, Abdominal examination : WNL
• CNS: Altered sensorium; but answering to questions
• Respiratory system : Deep and rapid respiration with rate of 24 bpm
with fruity odour
• Fundoscopy : WNL
• Spot Blood glucose : 475 mg/dL [70-140mg/dL]
• S. Na : 131 meq/L [135-145 meq/dL]
• S. K : 5.3meq/L [3.5-5.0 meq/dL]
• S. Cl : 95meq/L [101-109 meq/dL]
• BUN : 35 mg/dL
• ABG:
pH: 7.12 [7.35-7.45]
PC𝑂2 : 24mmHg [35-45mmHg]
P𝑂2 : 95mmHg [≥ 79mmHg]
• Urine Analysis:
Glucose : (+++) [+= 50 mg/dL,++ =100 mg/dL,+++= 300 mg/dL]
Ketone : (+++) [+=16 mg/dL, ++= 52 mg/dL, +++=156 mg/dL]
Provisional Diagnosis
DKA Or HHS
Features Ketoacidosis Non-ketoacidosis Hyper osmolarity
coma
Glucose (mg/dL) High (~ 400mg/dL) Very high (≥800 mg/dL)

Sodium (mmol/L) Hyponatremia Hypernatremia

Bicarbonate Moderate/Severely decrease Normal/Slightly reduced

(mmol/L) (<12.0)
Breathing Hyperventilation Normal

Dehydration Prominent Prominent

Ketones Present Scanty-Absent

T1DM in DKA
 Features T1 Diabetes Mellitus T2 Diabetes Mellitus
Clinical • Onset: Usually childhood and adolescent • Usually adults
• Normal weight-weight loss preceding • Majority are obese
diagnosis • Insulin function is compromised
• Progressive in Insulin levels • No Islet antibodies
• Circulating islet autoantibodies (anti-
insulin, Anti-GAD, anti-ICA512) • HHS is acute complication
• DKA is acute complication

Genetics • Major linkage to MHC class 2 and • No HLA linkage; more to candidate diabetogenic
polymorphism in CTLA4 and PTPN22 and and obesity related (TCF7l2, PPARG, FTO, etc.)
insulin gene VTNRs

Pathogenesis • Dysfunction in T-cell selection & • Insulin resistance in peripheral tissues and
regulation leading to breakdown in self Obesity associated factors linked to
tolerance to islet autoantigens pathogenesis of insulin resistance

Pathology • Insulitis (inflammatory infiltrate of T cells • No Insulitis; Amyloid deposition in islets

and macrophages) β-cell depletion, islet Mild ) β-cell depletion
atrophy