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A 70 yo male with new DKA???

Dr. Tang presents a 70 yo gentleman with PMH significant for SCLC with new onset DKA in the setting of atezolizumab (immune checkpoint inhibitor).


Teaching points:


1. What are the diagnostic criteria for DKA vs. HHS?


  • Often, Beta-hydroxybutyrate is present in DKA; however the level does not correlate with the severity of DKA

  • Acetone and Acetoacetate are other breakdown products of ketogenesis and are not as frequently measured



2. Management strategies for DKA:

  • Correct hypovolemia and hyperosmolality

  • Correct/replete potassium prior to starting insulin (IF K<3.3, need to replete K before starting insulin therapy).

  • Give IV insulin to halt ketogenesis


3. Checkpoint inhibitor-induced Diabetes:

  • These new immunotherapies target receptor:ligand pairs and modulate T-cell activity

  • They are highly associated with development of autoimmune diseases

  • Important to check A1C prior to and during treatment with immune checkpoint inhibitors

  • Most common presentation with checkpoint-inhibitor-induced autoimmune diabetes presents with DKA



4. What are some potential paraneoplastic syndromes associated with SCLC?

  • Hypercalcemia secondary to bony mets or tumor secretion of PTHrP, calcitriol or other cytokines --> anorexia, nausea, vomiting, constipation, lethargy, polyuria, polydipsia, dehydration

  • SiADH secretion: frequently caused by SCLC and results in hyponatremia --> anorexia, nausea, vomiting, cerebral edema

  • Neurologic syndromes: Lambert-Eaton myasthenic sydrome, cerebellar ataxia, sensory neuropathy, limbic encephalitis, encephalomyelitis, autonomic neuropathy, retinopathy, opsomyoclonus

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