P2.C060: Atypical Laboratory Findings in DKA with Cannabis Use

Introduction: Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes. If left untreated, it can lead to death. It is typically characterized by hyperglycemia, acidosis, serum bicarbonate less than 15 mEq/l and presence of ketones in the blood and/or urine. However, in prior case reports, adults have shown that cannabis users have differing laboratory findings in comparison to non-cannabis users. This may cause a delay in the recognition and treatment of DKA. We report a case of masked diabetic ketoacidosis in a young teen with cannabis use and newly diagnosed diabetes mellitus.

Case Description: Here we describe a case of 14-year-old with a past medical history of oppositional defiant disorder who complained of a 4 day history of sore throat and positive sick contacts at home. The day prior to hospital admission, he developed nausea and vomiting and was initially seen at his primary care physician who referred him to the emergency center. Initial work-up revealed a blood gas pH 7.16, point of care glucose >600 and ketone beta-hydroxybuterate >18 mmol/L (normal < 0.5). Urinalysis was also positive for glucose and ketones. Infection work-up including influenza A/B, rapid strep, and rapid mono were negative. Urine drug screen positive for cannabis. He was treated with antibiotics, fluid resuscitation, insulin bolus and initiated on insulin infusion and maintenance IV fluids (NS). He was transferred to a pediatric intensive care unit for further management. On arrival, he continued with hyperglycemia (>600), chemistry panel indicative of hypernatremia, elevated BUN and creatinine consistent with dehydration and normal bicarbonate. Venous blood gas obtained which noted a change in pH to normal level, slightly elevated PCO2 and persistently normal bicarbonate. Upon discussion with the Endocrinologist, decision made to continue treatment for DKA with intensive therapy including continuous insulin and fluids due to presence of ketones and hyperglycemia. Ketosis and hyperglycemia resolved within 24 hours but hypernatremia persistent with need for fluid correction of a profound total fluid deficit.

Discussion: There has been adult literature describing cannabis associated masking of diabetic ketoacidosis as well as how to differentiate DKA and hyperglycemic ketosis due to cannabis hyperemesis syndrome in adults with Type 1 diabetes. Namely, in patient who present with symptoms and laboratory findings of DKA with PH greater than 7.4, cannabis, cannabis use should be considered.

Conclusion: This case demonstrates the misleading presentation of DKA in a pediatric patient with cannabis use. With increasing cannabis use amongst the pediatric population, it is important for the medical team to consider the diagnosis of diabetic ketoacidosis in patient presenting with normal pH and normal bicarbonate in presence of hyperglycemia and ketosis. A delay in recognition and management may progress to worsening signs and symptoms and ultimately lead to increase in morbidity and mortality.