The patient is a middle-aged female, who presented to the emergency department with complaints of progressive fatigue, and occasional blurring of vision for three weeks. She also complained of nausea and vomiting for the last three weeks. There were no additional complaints.
The patient's past medical history was significant for type 2 diabetes mellitus on metformin, diagnosed at 35 years of age. The last HbA1c, four months prior to presentation, was 7.1. The patient also had a history of hypercholesterolemia, diagnosed ten years back, on atorvastatin 20 mg, which was increased to 80mg four months prior to admission. She also had hypertriglyceridemia (HTG), which was progressively worsening. Before admission, the last lipid level showed cholesterol of 883 mg/dL, TG 5336 mg/dL, and very low HDL. Other history was significant for hypertension, hypothyroidism, asthma, chronic tobacco use, and bipolar disorder. She had a positive family history of high triglycerides and lipids.
The patient's weight was 113 kg, height was 162.6cm, and BMI was 42.76 kg/m2 at the presentation time. Vital signs included a blood pressure of 202/95 mmHg, a pulse of 89 bpm, respiratory rate of 18 bpm, a temperature of 97.7° F, and oxygen saturation of 97% on room air. Physical examination was unremarkable.
Initial laboratory findings included normal complete blood count and routine chemistry that showed creatinine 0.63 mg/dl, sodium 129 mmol/l, potassium 4.4 mmol/l, chloride 94 mmol/l, CO2 5 mmol/l, and anion gap 30 mmol/l. Arterial blood gas (ABG) showed (pH 7.32, carbon dioxide partial pressure 44.4 mmHg, oxygen partial pressure 72.3 mmHg, and calculated bicarbonate [HCO3−] 22.8 mEq/l, lactate 9.12mmol/L), and random glucose of 163 mg/dl. Additionally, a lipid panel was drawn, which included total cholesterol 691 mg/dL, HDL cholesterol 25 mg/dl, direct LDL cholesterol < 70 mg/dl, triglycerides 5904 mg/dl. Serum osmolality was determined to be 298 mOsm/kg with an osmolal gap of 47mOsm/kg. Patients' lipase levels were normal, ketones were negative.
The patient had hyponatremia, low bicarbonate, and a high anion gap on the metabolic panel. Contrary to that, the patient had a normal pH and calculated bicarbonate levels on the ABG. The metabolic abnormalities were assumed to be spurious and related to the high TG levels. Due to risk of pancreatitis associated with such high TG levels, she was started on insulin infusion at 2U/hr, gradually increasing to 7U/hr with a strict low-fat diet. Atorvastatin 80mg and fenofibrate were also added. Patients' triglyceride improved to 1071 on day 7 of hospitalization, measured bicarbonate improved to 23, serum sodium to 141, anion gap to 11. She was subsequently transitioned to subcutaneous insulin on day 7 of her hospital stay and discharged on 20U long-acting insulin twice daily with 6U mealtime insulin on day 8. TG levels at the time of discharge were 1071. On follow-up a month later, the patient was feeling better, and her fatigue had resolved. She complied with her medications, and triglyceride levels had decreased to 506. There were no adverse events on the follow-up.