Extreme Insulin Resistance in a Patient with Diabetes Ketoacidosis and Acute Myocardial Infarction

Table 1

Results of relevant laboratory work up.

Admission lab
Hemoglobin A1c	8.8%
Lipid profile	LDL 90 mg/dL (ref < 100 mg/dL); Triglycerides 281 mg/dL (ref < 250 mg/dL)
CBC	No leucopenia with normal differential count. mild normocytic anemia
Autoimmune work up
ANA	Negative
pANCA/cANCA	Negative
Complement levels	Normal
ESR	55
ds DNA	1 (ref < 4 IU/mL)
Others
Insulin*	34 (ref < 17 𝜇IU/mL)
C-peptide^∧	2.62 (ref 0.8–3.1 ng/mL)
Glucagon	283 (ref < 134 pg/mL)
Anti-GAD (Glutamic Acid Decarboxylase)	<1 (ref <1)
Insulin autoantibody	>50 (ref < 0.4 U/mL)
24 hr urine free cortisol	66 (ref 4–50 mcg/24 h)
Plasma metanephrine	<25 (ref ≤ 57 pg/mL)
Plasma normetanephrine	99 (ref ≤ 148 pg/mL)
Plasma total metanephrines	99 (ref ≤ 205 pg/mL)
IGF-1	66 (ref 41–279 ng/mL)
TSH	1.12 (ref 0.73–4.6 mIU/mL)
SPEP (serum protein electrophoresis)	No monoclonal spike
Additional comments
Lowest pH was 7.24 with serum bicarbonate level of 8 mmol/L and anion gap of 22 on day 4
Highest BUN and creatinine were 74 mg/dL and 3.7 mg/dL respectively on day 5
Highest BNP was 2047 pg/mL on day 5

*Insulin level obtained on day 4 with corresponding glucose level at 749 mg/dL and insulin infusion rate at 32 units/hr.
^∧C-peptide level obtained on day 8 with corresponding glucose level at 108 mg/dL.