Normal Saline Versus Low Chloride Solutions in Treatment of Diabetic Ketoacidosis: A Systematic Review of Clinical Trials.

Traditionally, normal saline solution (NSS) has been the fluid of choice in diabetic ketoacidosis (DKA) patients, but the NSS is an acidic fluid and may lead to the delayed resolution of DKA. A systemic review search was conducted on PubMed, Embase, and Central Cochrane Registry to compare the efficacy of low chloride solutions with normal saline solution in DKA resolution. Randomized clinical trials with normal saline as a control arm and low chloride solutions as an intervention arm were included. Four studies were included in the analysis. The investigated outcomes, including time to resolution for DKA and duration of insulin infusion, varied depending on the endpoint were reported in the studies. Overall, balanced solutions were generally associated with faster correction of pH. The time to reach overall DKA endpoints was comparable in both groups. We concluded that crystalloid solutions may be used as an initial resuscitation fluid in the DKA population and may lead to earlier resolution of acidosis. More clinical trial data is required to reach statistical significance for the hypothesis.

Co-infection of hepatitis E virus and Plasmodium falciparum malaria: A genuine risk in sub-Saharan Africa.

BACKGROUND: There is a high prevalence of malaria and viral hepatitis in South Africa. Co-infection with Plasmodium malaria (leading to cerebral malaria) and hepatitis E virus (HEV) is a rare phenomenon. CASE PRESENTATION: A 33-year-old African American male with no past medical history developed altered mental status on his return from Ivory Coast. His blood tests were significant for renal and liver failure and a high Plasmodium parasite burden of 33% on the blood smear. Interestingly, he also had a positive result for hepatitis E IgM. The patient was effectively treated with aggressive hydration and intravenous (IV) artesunate. CONCLUSION: Our report is the first to our knowledge in the cerebral malaria literature on a patient with hepatitis E co-infection. This exciting case emphasizes the importance of considering all kinds of endemic infectious diseases when evaluating sick returning travelers presenting to the emergency department.

Epstein-Barr virus (EBV) induced pneumonitis in an immunocompetent adult: A case report.

Epstein Barr Virus (EBV) is one of the herpes viruses that is responsible for causing infectious mononucleosis, lymphomas, and carcinomas primarily in immunocompromised individuals. We present a case of EBV-induced pneumonitis in an immunocompetent female, successfully treated with steroids. The patient is a 70 year-old female with a history of infectious mononucleosis in her teens who presented to the emergency room with worsening shortness of breath, associated with cough and fever. She underwent extensive work up and her serologic workup revealed positive anti-EBV antibodies, pointing towards the diagnosis of EBV induced pneumonitis. EBV-induced Pneumonitis is a very rare entity and is especially hardly seen among immunocompetent individuals. This interesting case shows that in this new era of viral pneumonias, EBV induced pneumonitis should be considered among differentials when dealing with lung infections. Prompt initiation of treatment with steroids or antiviral medication may result in complete recovery. The choices among treatment options can be individualized according to the severity of disease, course of disease progression, and side effect profile of medications. In our case we were able to successfully treat the patient with high dose steroids only.

Locked-in Syndrome in a Young Patient Due to SARS-CoV-2: A Case Report.

Coronavirus disease 2019 (COVID-19), apart from commonly involving the respiratory system, has its impact on the central nervous system, with a wide spectrum of clinical presentations ranging from headaches to ischemic strokes. The ongoing research regarding this novel disease has found that there is a very high prevalence of thrombotic episodes especially in critically ill patients when compared to severe presentation of other viral illnesses. This COVID-19-associated coagulopathy has a very complex etiology with the ability to form thrombus in arteries, veins, and microvasculatures of different organs. We present a unique case of a young woman with underlying COVID-19 who unfortunately developed locked-in syndrome due to bilateral pontine infarction during the course of her illness.

SGLT-2 Inhibitors-a Culprit of Diabetic Ketoacidosis Postbariatric Surgery.

Sodium-glucose cotransporter-2 SGLT2 inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. They have grown increasingly popular over recent years, as they have been shown to have some protective effects on the heart and kidneys, both organ systems that diabetes mellitus has shown to have deleterious effect on over time. Despite their growing popularity, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a case series of three cases of euglycemic DKA postbariatric surgery in patients with an underlying history of type 2 diabetes mellitus, who were being treated with SGLT2 inhibitors prior to the surgery. All three patients reported to the emergency room with signs, symptoms, and clinical findings of euglycemic DKA. The AACE recommends SGLT2 inhibitors to be discontinued at least 24 hours prior to surgery and resumed when a patient resumes a normal diet. Our patients presented with euglycemic DKA after bariatric surgery, and we recommend more research should be done targeted at the prolonged postoperative course of patients on SGLT-2 inhibitors and into creating specific guidelines for their use after bariatric surgery.

Prevalence of microvascular complications in newly diagnosed patients with type 2 diabetes.

BACKGROUND & OBJECTIVE: Microvascular complications are the major outcome of type 2 Diabetes Mellitus progression, which reduce the quality of life, incur heavy economic burdens to the health care system and increase diabetic mortality. The aims of this study were to assess the prevalence of microvascular complications among newly diagnosed type 2 diabetic patients and to analyze the association between these complications and poor glycemic control. METHODS: This cross sectional hospital based study was carried out in Diabetic Clinic of Shaikh Zayed Postgraduate Medical Institute, Lahore Pakistan. The study was conducted from November 2011 to November 2012 among newly diagnosed type 2 diabetic patients. Relevant information of all patients was recorded with the help of a proforma. They were investigated for retinopathy, nephropathy and neuropathy. RESULTS: We have divided the patients into two groups: Group I with good glycemic control (HbA1c <6.5) and group II with poor glycemic control (HbA1c >6.5). In group II microvascular complications were 89.8%. Neuropathy, nephropathy and retinopathy were present in 68.5%, 56.2% and 31.4% respectively. These similar percentages in Group I were 50%, 0% and 31% respectively and are significantly lower. CONCLUSION: The study showed that even in newly diagnosed type 2 diabetic patients who had poor glycemic control, frequency of microvascular complications is much higher as compared to those who had average glycemic control. Thus tight glycemic control does count even in newly diagnosed type 2 diabetics to prevent and minimize the occurrence of complications.