Rhabdomyolysis and Acute Pancreatitis in Diabetic Ketoacidosis: A Case Report and Review of Literature

Diabetic ketoacidosis (DKA) is a life-threatening complication in patients with Type 1 or Type II. Diabetes Mellitus resulting in fluid shifts, electrolytes im-balance and acid-base disorders, can lead to multi-organ Failure. The Pancreas and skeletal muscles are not commonly affected in DKA. We present a case of 41-year-old female who was initially admitted in intensive care unit for treat-ment of Diabetic ketoacidosis, and was treated appropriately later she com-plained of abdominal pain and generalized myalgia. Hospital course was com-plicated with Acute pancreatitis and Rhabdomyolysis. Serum electrolytes were significant for hypo-phosphatemia. Workup for myositis and acute pancreatitis were negative. The exact etiology is unknown, but it is proposed in many literature articles that serum hyper-osmolarity and/or electrolyte abnormalities can be the culprits in triggering the complications.


Introduction
Diabetic ketoacidosis (DKA) is a life-threatening complication in patients with Type 1 or Type II Diabetes Mellitus. The Pancreas and skeletal muscles are not commonly affected in DKA but fluid shifts along with changes in the serum osmolarities, electrolyte imbalance, and acid-base disorders can lead to multi-organ dysfunction such as the one presented here. The exact etiology is unknown, but it is proposed in many literature articles that serum hyper-osmolarity and/or electrolyte abnormalities can be the common culprits in triggering the complications.

Case Presentation
We present a case of a 41-year-old female with a past medical history of Ulcera-

Discussion
Diabetic ketoacidosis (DKA) can be life-threatening in patients with uncontrolled Diabetes Mellitus (DM) especially in patients with type II Diabetes Mellitus. Acute pancreatitis (AP) and non-traumatic rhabdomyolysis can occur in severe cases of DKA which can increase the mortality if left undetected [1]. Rhabdomyolysis is a syndrome characterized by myonecrosis and the release of intracellular muscle constituents i.e. Creatinine Kinase (CK) enzymes and myoglobin into the circulation [1]. The severity ranges from asymptomatic cases to life-threatening manifestations associated with extreme enzyme elevations, electrolyte imbalances, and acute kidney injury [1]. Common clinical symptoms are muscle pain, dark urine, and generalized weakness. Rhabdomyolysis is classified into three groups: 1) traumatic; 2) non-traumatic exertional; and 3) non-traumatic non-exertional [1]. Although the exact mechanism of action of a hyperosmolar state causing rhabdomyolysis remains unclear, there have been theories postulating the etiology. One possibility is that hyperosmolarity can damage the myocytes, also serum electrolyte abnormalities such as Hypernatremia, Hypokalemia, and Hypophosphatemia seen in hyperosmolar hyperglycemic states can also contribute to rhabdomyolysis. There is a rapid shift of electrolytes especially Potassium and Phosphate from extracellular to intracellular with intravenous insulin infusions in diabetic emergencies. Rhabdomyolysis itself is known to cause hypokalemia in isolated cases as well.
In the review of the literature, Amin et al. [1] presented a case of Rhabdomyolysis-Induced acute kidney injury in DKA and emphasized the necessity to rule out other causes of renal failure in patients admitted for Diabetic emergencies to decrease morbidity and mortality. Al-Azzawi et al. [2], stated Rhabdomyolysis as an underdiagnosed complication of DKA and emphasized that the serum electrolyte abnormalities have significant implications on the recovery of patients. A cross-sectional study was carried out in the emergency department of Baghdad, where 43 patients with Type 1 Diabetes Mellitus presenting with diabetic ketoacidosis were enrolled. The incidence of rhabdomyolysis was 6.98% as was seen in 3 cases.
Shah SK et al. [3], presented an interesting case of rhabdomyolysis secondary to hypophosphatemia in the setting of DKA. The possible cause of rhabdomyolysis was attributed to severe hypophosphatemia (minimum serum phosphate, as low as 0.8 mg/dL). Wang LM et al. [4], found 44 cases (16.60%) of Rhabdomyolysis in 265 diabetic emergencies (including DKA or hyperosmolar, or both).
The diagnosis was based on 1) serum creatinine kinase (CK) > 1000 IU/l and 2) the absence of acute myocardial infarction, stroke, and end-stage renal disease.
In our case, the most common causes of AP were ruled out, including alcoholism, gallstones, hypertriglyceridemia, and autoimmune causes. For the rhabdomyolysis, inflammatory myositis and infectious myositis were ruled out with the help of muscle biopsy leaving hypophosphatemia resulted in the management of DKA as the possible culprit of rhabdomyolysis in DKA

Conclusion
Due to the high mortality rates associated with rhabdomyolysis and hyperosmolar hyperglycemic syndrome (HHS) and DKA, it is important to establish an early diagnosis. Routine screening by ordering CPK levels should be considered in highly suspected patients admitted with diabetic emergencies. Acute kidney injury associated with rhabdomyolysis plays a vital role in the recovery and duration of the hospital stay. Rhabdomyolysis should be suspected in patients presenting with diabetic emergencies and acute kidney injury when common causes have been excluded and treated accordingly without improvement of kidney functions.