Uncontrolled diabetes leading to pneumonia, diabetic ketoacidosis and refractory shock: a vicious cycle

Diabetes mellitus (DM) puts people at risk of infections and metabolic crises diabetic ketoacidosis (DKA). Another common precipitant is pneumonia, it has the power to aggravate hemodynamic instability by causing systemic inflammation, and acidosis. A 52-year-old male who has had a history of poorly controlled type 2 DM presented with fever, cough, breathlessness, and altered sensorium in the last three days. Patient was febrile (38.6o C), tachycardic (124 beats/min), hypotensive (84/56 mmHg), tachypneic (32 breaths/min), and hypoxic (SpO2 86% on room air) at the time of admission. Auscultation of the chest showed signs of crepitation in the lower right lung fields. Incidents revealed random blood glucose 486 mg/dl, arterial pH 7.05, HCO3-8 mmol/L, PaCO2 18 mmHg and presence of serum ketones, which is typical of DKA. The X-ray of the chest showed right-lower-lobe consolidation. Despite the fluid resuscitation, insulin infusion, and inotropic support, hypotension prevailed until the restoration of acidosis. Optimization of antibiotics was by testing of external procalcitonin. Upon stabilization of the pH, the patient was discharged on day 9 with strict glycemic control recommendations. The combination of infection, DKA, and shock is highly pathophysiological interactive as evidenced in this case. Metabolic acidosis needs to be corrected to reinstate the vascular responsiveness. The ability to adjust to changing circumstances and make clinical decisions is crucial to the provision of the best care in resource-restricted settings.