Life-Threatening Hypertriglyceridemia in Diabetic Ketoacidosis Successfully Managed With Therapeutic Plasma Exchange: A Case Report and Review of Literature.

Extremely severe hypertriglyceridemia associated with diabetic ketoacidosis (DKA), shock, cerebral edema, acute kidney injury (AKI), and pneumonia represents a rare but life-threatening clinical emergency, particularly when occurring as the initial presentation of previously undiagnosed diabetes mellitus (DM). In such critically ill patients, prompt management is challenging because clear evidence-based guidelines regarding the role and timing of therapeutic plasma exchange (TPE) remain limited. To our knowledge, this is the first reported case from Bangladesh describing severe combined hyperlipidemia with DKA as the initial manifestation of DM requiring urgent TPE. A 15-year-old girl presented with altered consciousness and hemodynamic instability. She underwent immediate intubation upon admission due to severe metabolic decompensation. Further evaluation revealed DKA with extremely severe hypertriglyceridemia associated with combined hyperlipidemia. On the second day of hospitalization, her condition was further complicated by pneumonia and AKI. Despite standard intensive management, including insulin therapy, fluid resuscitation, and supportive care, no significant overall clinical improvement was observed. Considering the progressive deterioration and risk of fatal complications, TPE was initiated on day 3. Following a single session of TPE, her clinical status improved dramatically, with rapid hemodynamic stabilization and metabolic recovery, allowing successful weaning from ventilatory support within 24 hours. This case highlights that TPE may be a valuable adjunctive treatment in carefully selected patients with DKA complicated by extremely severe hypertriglyceridemia and multiorgan dysfunction when conventional therapy fails to produce adequate clinical improvement. We also review previously reported cases and discuss the potential role of TPE in managing this rare but life-threatening condition. As plasmapheresis remains costly and less accessible in resource-limited settings like Bangladesh, greater clinical awareness and further evidence are needed to guide future management recommendations for similar critically ill patients.