Fueling the Body

PEARLS Case 3.4a: Joe Tavernisi

Diabetes Mellitus
Student Version
May not be used or reproduced without written permission from SOM

GOAL:
Understand the consequences of the absence of insulin on glucose homeostasis. Understand how
exogenous insulin therapy seeks to mimic endogenous insulin secretion.
CASE VIGNETTE:
Joe Tavernisi is a 16 year-old man with type 1 diabetes mellitus who goes to the Emergency
Department because he has been experiencing nausea, vomiting, and crampy abdominal pain.
Today he began to urinate every 1-2 hours, and became intensely thirsty. He has vomited 8 times
in the past 48 hours, and has been unable to retain oral fluids since yesterday evening.
He tells the triage nurse that he has had type I diabetes since age 9 and he takes both NPH and
regular insulin before breakfast and dinner. Joes most recent hemoglobin A1C was 9.2. Joe
says that it has been explained to him in the past that his body does not make the insulin
necessary to regulate his blood sugar. He tells the nurse Since I was not able to eat very much
yesterday, I stopped taking my insulin in order to avoid low blood sugar.
Physical examination:
General: Breathing rapidly, fruity breath
Vital signs: BP 135/88, Pulse 120, RR 32, Temp 37.44C
HEENT: mouth is very dry
Chest: clear to auscultation bilaterally
CV: tachycardic
Abd: non-tender
Ext: dry with tenting of skin
The laboratory results show:
General Chemistry
Test Name
Glucose
Bicarbonate
Serum Ketones

pH Arterial

450
8
High
Blood Gases
7.0

Units
mg/dL
mM

Ref Range
[70-99]
[24-28]
[0.1-0.2milli molar
overnight fast]

[7.35-7.45]

Glucose Metabolism

Hb A1C

13
Urinalysis
Very high
Large

Glucose
Ketones

[4.0-5.6]

[Negative]
[Negative]

Dr. Paldo starts appropriate therapy immediately for diabetic ketoacidosis (DKA) and tells Joe
that his insulin levels must be very low and his glucagon levels very high for him to be so sick
right now. Dr. Paldo speaks with Joe who says that he is tired of having diabetes and often skips
his insulin injections. He tests his blood glucose just once daily, and does not adjust his insulin
according to his blood glucose levels. He missed his last follow-up appointment to check his
blood glucose, lipid profile and urinary protein levels. He also has not had an eye exam recently.
Joes glucose, pH, bicarbonate and fluid status improve with treatment, and he is discharged the
following day on a new insulin regimen: one injection of insulin glargine at bedtime, with
additional injections of insulin lispro before each meal. Dr. Paldo also gives him an emergency
glucagon kit to use in case he develops very low blood sugar.
The next week, Dr. Paldo presents Joe's case to the team of residents, third and fourth year
medical students on the Endocrine Service. Dr. Paldo wants them to understand the similarities
between DKA and the normal physiological adaptation to long-term starvation. He describes the
following study: In 1969, at Brigham Hospital (Boston), a group of obese volunteers were
recruited for a research study. These patients were housed in the Center of the Peter Bent
Brigham Hospital for Therapeutic Starvation and deprived of food for periods of up to 6 weeks.
Those who underwent prolonged periods of starvation received water, salt tablets and
multivitamins supplements. The research subjects were closely monitored and blood samples
were drawn after a meal, after IV glucose infusion in some subjects, after 12 hours of fasting,
and every day for the duration of fasting. Measurements were made to determine the levels of
insulin, free fatty acids, ketones, glucose and glycerol (Table 1).
Days of Fasting
3
10

0
Plasma free fatty
acids
Blood ketones
Blood glycerol
Blood glucose
Serum insulin

0.71
0.10
0.92
4.79
37

1.25
1.62
0.11
3.63
20
Table 1

1.36
5.30
0.11
3.79
20

38
1.60 (millimoles per litre)
7.19 (millimoles per litre)
0.12 (millimoles per litre)
3.70 (millimoles per litre)
(microunits per
14 milliliter)

Dr. Paldo continues At the conclusion of the experiment, the volunteers had lost 14.0 24.7 kg
of body mass. The patients were relatively healthy and didnt suffer any consequences from the
starvation. Can anybody tell me why their prolonged fast didn't have any deleterious effects,
whereas Joe's condition was potentially life threatening?