Ketosis Prone Diabetes in an Obese Male Adolescent: A Case Report

Abstract Introduction: Ketone-prone diabetes (KPD) is an atypical type of diabetes with features from both Type 1 and 2 diabetes, which may lead to its misdiagnosis. Patients usually present with an attack of DKA, but after its resolution, Insulin can be discontinued gradually in most patients with the maintenance of sufficient glycemic control with oral hypoglycemic medications. Clinical Case: A 14 -year-old Saudi male student, presented to the emergency department of our tertiary hospital in November 2017 complaining of nausea and vomiting of two days duration proceeded by a one-week history of generalized fatigue, polydipsia, and polyuria. The patient suffered from long-standing obesity since childhood; otherwise, past medical history was unremarkable. Family history was positive for Type II diabetes in his mother at the age of 48. On examination, the patient was dehydrated, tachypneic, and obese with a BMI of 34 kg/m2 and has patches of acanthosis nigricans over the neck and both axillae. Laboratory investigations showed blood glucose of 455 mg/dL, metabolic acidosis with a pH of 7.22, HCO3 of 11, and a high anion gap of 17, with urine being strongly positive for ketones (++++), HbA1c was 11.6%, and lipid profile showed dyslipidemia. The patient was diagnosed with diabetes ketoacidosis (DKA) and managed with Fluid, Insulin, and potassium infusions according to the Hospital’s DKA protocol. DKA resolved, and the patient was discharged with the impression of ketone prone diabetes based on the presentation of DKA along with features of insulin resistance. Discharge medications were Insulin Glargine 30 units SC once daily, Metformin 500 mg twice daily, and Gliclazide 60 mg Once daily. He was educated on usage and titration of insulin dosage according to glucose readings and monitoring. In subsequent follow-ups as an outpatient, it was noticed that the insulin requirements were gradually declining until it was possible to stop it completely after around six months of follow-up. The patient was transitioned from insulin to GLP-1 agonist (Liraglutide), which helped to achieve significant weight loss. After about one year, Liraglutide (Victoza) was not available in the hospital. However, the patient was controlled on Metformin and Gliclazide. Consequently, the patient has been in remission with adequate glycemic control and had not developed another attack of DKA. Latest review in the clinic in April 2020 showed his BMI of 27.4 kg/m2 and HbA1C of 7.5%. Conclusion: Although it is a rare and atypical type of diabetes, Ketosis Prone diabetes should be kept in mind when a patient presents with DKA but has features of insulin resistance to avoid misdiagnosis and inappropriate management, with proper education to patients and their families on the importance to titrate insulin requirements.