Diabetes ketoacidosis in L-asparaginase therapy

Abstract

Background: Diabetic ketoacidosis (DKA) as a complication of Lasparaginase therapy in children with acute lymphoblastic leukemia (ALL) is rare. We report a patient with B-C ell ALL who developed DKA while on treatment with L-asparaginase. Case: E.C, 10 years old female admitted due abdominal pain. Patient is a diagnosed case of ALL presenting with body weakness, anemia and hematoma and was confirmed with flow cytometry since 2 months prior to her present admission. She has been receiving 8 doses of L-asparaginase and Prednisone (60 mg/day for a week then 40 mg/day for 3 weeks) for one month before her admission. One week prior to hospitalization, the patient had nocturia, polyuria and polydipsia. On the day of admission, she had sudden onset of dyspnea associated with severe abdominal pain and vomiting. She came in non-ambulatory, in cardiorespiratory distress with BP: 100/ 70 mmHg, HR: 150/min, RR: 60/min, Temp: 37.3°C. Pertinent physical exam showed signs of dehydration with abdominal tenderness, and signs of circulatory compromise. Fluid resuscitation was immediately given. The initial assessment at the ERwas pancreatitis but the serum amylase and lipase were normal. Other lab work-ups showed blood glucose of 26.8 mmol/l (NV: 3.08-7.92), sodium at 115 mmol/l (NV: 132-143), potassium of 3.3, Chloride at 88 mmol/l (NV: 98-116). Blood gas showed ph of 7.1, a pCO2: 50, HCO3 at 3.7, and a base deficit of -22.5 mmol/l. Urinalysis showed +4 of glucose and +3 of ketones. The patient was then managed as a case of DKA and fluid resuscitation was continued and insulin drip was started. The HbA1c level at diagnosis was 11.4% but the C-peptide was normal. Patient condition improved and was discharged with insulin injection. The insulin was discontinued after completion of her induction phase and with normalization of blood glucose. Conclusion: Early recognition of the precipitating factors for DKA is important to prevent L-asparaginase fatal consequences.