Case Discussion <Case History> A 46 years old male patient was quite healthy before. He suffered from polyuria, polydipsia and polyphagia since 6 months ago. Progressive body weight loss (12 Kg within 6 months) and generalized malaise were also noted during this period. He did not pay any attention to it until cough with yellowish sputum and high fever occurred 3 days ago. Other associated symptoms including dyspnea, abdominal pain and nausea. No vomiting or diarrhea was noted. Because of worsening of dyspnea and fever, he was sent to our Emergency Room for help. On physical examinations, this patient appeared very ill-looking and tachypnea. His consciousness was clear and oriented. The blood pressure was 165/98 mmHg, body temperature was 39.60C, pulse rate was 118 /min, and respiratory rate was 28/min. The body height was 168 cm, body weight was 76 Kg, and BMI was 26.9 Kg/m2. The head was normal. The conjunctivae were not pale and the sclerae were not icteric. The neck was supple without lymphadenopathy. The jugular veins were not engorged. The thyroid was not enlarged. The heart sounds were regular without murmur. Inspiratory crackles and wheezing were found over right lung field. The abdomen was soft and flat, diffuse tenderness was noted but without rebound tenderness. The liver and spleen were not palpable. The extremities moved freely without edema. <Laboratory Data> CBC WBC K/μL RBC K/μL  Hb g/dL Hct % MCV fL MCH pg MCHC g/dL PLT K/μL Seg % Eos % Baso % Lym % 19.3  4900 15.5  45.6 98 30.8 37 258 89.8 2.7  1.3 6.2 Biochemestry   Alb g/dL Glo g/dL T-Bil mg/dL D-Bil mg/dL AST U/L ALT U/L ALP U/L LDH U/L BUN mg/dL Crea mg/dL 3.9 3.0 0.6 0.2 32 26 134 385 35.2 1.3 UA mg/dL Na Meq/L K Meq/L Cl Meq/L (T)Ca mg/dL Sugar mg/dL CRP μg/ml HbA1c % Lipase IU/L Osmo mOsm/Kg 5.2 130 4.2 102 8.9 485 183 14.2 48 295  Arterial blood gas (room air)  PH PaCO2 mmHg PaO2 mmHg HCO3- Meq/L SaO2 % 7.253 26 112 9.8 99.6   Urine analysis    Ketone Sugar mg/dL WBC /HPF RBC /HPF 3+ >1.0 0-2 0-2  Imaging Studies: *Chest PA: Air-space lesions over right lung *Plain abdomen film: no positive findings *12 leads EKG: Sinus tachycardia <病情分析>      糖尿病是一種血糖代謝異常的疾病，造成血糖升高的原因包括：胰島素分泌減少、血糖利用減少或是血糖生成增加，一般分成四種type：type 1 （因βcell受破壞導致胰島素生成減少）、type 2（因胰島素生成功能異常或是有insulin resistance）、other type（βcell或是胰島素的gene突變、胰臟發炎或是胰臟手術引起、藥物）以及GDM（妊娠高血糖）。       糖尿病急性併發症是指胰島素缺乏導致對生命有立即威脅的代謝異常，一般常見的是糖尿病酮酸血症（DKA）和高血糖高滲透壓非酮體性症候群（HHNK）；糖尿病酮酸血症好發於胰島素生成減少的type1 DM，當胰島素分泌不足或壓力荷爾蒙分泌過度時，血液中的葡萄糖會因來源增加和利用減少導致濃度升高，此時脂肪組織釋放脂肪酸的速度增加，再加上肝臟將脂肪酸轉換成酮體的功能亢進，使得血液中酮體濃度上昇，造成代謝性酸中毒。       典型DKA的臨床表徵為：發病前數日有多喝多尿的症狀，而且常伴隨著厭食、噁心、嘔吐等表徵，有時以腹痛為主要表現；實驗室檢查的發現主要為高血糖、高酮血症和酸中毒。       DKA的治療目標在於抑制肝臟葡萄糖釋放和促進週邊組織葡萄糖利用、校正酮酸血症，因此要注意胰島素的使用以及水分和電解質的補充；此外要避免因治療導致之併發症，水分補充、胰島素使用以及酸血症的校正均會造成血中鉀離子濃度下降，因此治療中須仔細的檢視血中鉀離子濃度並補充適當的鉀離子以防止低血鉀的發生，而且當血糖低於250mg/dl時，須補充適當的葡萄糖以防止低血糖和腦水腫的發生。       高血糖高滲透壓非酮體性症候群是指血液中葡萄糖濃度升高、滲透壓升高，同時沒有明顯的酮體；臨床徵狀常出現脫水、體液不足和意識障礙等現象，易發生於年老type2 DM患者，治療上和上述DKA的治療相似；在HHNK常併發致死的梗塞症，特別是在低血壓、高滲透壓、脫水、血液濃縮和高黏性導致局部循環不足時較易發生，故在HHNK治療時須特別注意梗塞正並予以適當治療。       糖尿病慢性併發症包括小血管病變以及大血管病變，小血管病變是指視網膜病變、神經病變和腎病變，而大血管病變是指冠狀動脈、腦血管以及週邊血管疾病；其中大血管病變往往是病人死亡的主要原因。                                             繼續教育考題 1. (A) 這位病人最有可能的診斷為： (1) HHNK, (2) DKA, (3) Pneumonia, (4) APN A 2+3 B 1+3 C 2+4 D 1+4 2. (A) 這位病人之anion gap為： A 上升 B 下降 C 正常 D 無法計算 3. (D) 有關這位病人的治療，何者為是？ A Empirical antibiotics B Insulin therapy C Fluid and electrolytes supplement D 以上皆是 4. (C) 下列胰島素的劑量對這位病人目前的狀況何者較為適宜？ A Regular insulin 8u Tid subcutaneous B Mixtard 12u, 6u Bid subcutaneous C Regular insulin 10 – 15 u intravenous bolus, then keep regular insulin 0.1u/kg/hr continuous infusion D 視病人的血糖值而定 5. (D) 在治療當中，下列何者可供為治療效果的參考？ (1). Improved anion gap, (2). Improved metabolic acidosis, (3). Improved blood sugar level, (4). Disappearance of ketone body A 1+2+3 B 2+3+4 C 1+3+4 D 1+2+3+4 6. (C) 有關這位病人糖尿病的診斷分類，何者為是？ A 病人發生DKA，故必定為type 1 DM B 病人有家族史，又較肥胖，故必定為type 2 DM C 不一定。需再參考Islet cell antibody, glutamic acid decarboxylase antibody and C-peptide level才能正確的診斷 D 病人非為典型的type 1 DM 和type 2 DM, 故應為other type DM 7. (B) 糖尿病的慢性併發症中，大血管病變包括： (1) Cardiovascular disease, (2) Neuropathy, (3) Nephropathy, (4) Cerebrovascular disease, (5) Retinopathy A 1+2 B 1+4 C 2+3+5 D 1+4+5 8. (C) 承上題，糖尿病的慢性併發症中，小血管病變包括： A 1+2 B 1+4 C 2+3+5 D 1+4+5 9. (B) 何謂DM nephropathy 之microalbuminuria stage？ A 24 hours urine albumin excretion between 0 – 30 mg B 24 hours urine albumin excretion between 30 – 300 mg C 24 hours urine albumin excretion greater than 300 mg D 24 hours urine albumin excretion greater than 3.5 g 10. (A) 對於DM nephropathy, 下列何者為首選用藥？ (1) ACE inhibitor, (2) Calcium channel blocker, (3) β-blocker, (4) Diuretics A  1 B  2 C  3 D  4

答案解說 DKA 的診斷criteria 為 high anion gap metabolic acidosis, presence of ketone body and high blood sugar level (often > 300 mg/dl). 再加上病人有明顯的呼吸道症狀及Chest PA view上的pneumonia patch, 診斷應無困難。 Anion gap = Na – [Cl + HCO3], 正常值為10 – 14, 這位病人的anion gap = 19, 故應為增加的。 題目上的項目皆為治療DKA合併肺炎所需特別注意的事項。  DKA開始使用的胰島素劑量為Regular insulin 10 – 15 u intravenous bolus, then keep regular insulin 0.1u/kg/hr continuous infusion. 評估DKA的治療效果有下列項目：(1). Improved anion gap, (2). Improved metabolic acidosis, (3). Improved blood sugar level, (4). Disappear of ketone body. 並非所有發生DKA的病人皆為type 1 DM. Type 2 DM 的病人亦有可能發生DKA。故要診斷糖尿病的類型，需再參考Islet cell antibody, glutamic acid decarboxylase antibody and C-peptide level才能正確的診斷。 糖尿病的慢性併發症中，大血管病變包括：Cardiovascular disease and cerebrovascular disease. 糖尿病的慢性併發症中，小血管病變包括：Neuropathy, nephropathy, and retinopathy DM nephropathy 之microalbuminuria stage的定義為24 hours urine albumin excretion between 30 – 300 mg. DM nephropathy 之首選用藥為ACE inhibitors. Top of Page