Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication of Type I Diabetes, often presenting with polyuria and polydipsia. Severe insulin deficiency may also trigger hypertriglyceridemia, increasing the risk of acute pancreatitis. We present a case in which the only presenting symptom was bilateral hand pain, despite concurrent DKA and severe hypertriglyceridemia.
Description: A 23-year-old woman with Type I Diabetes (TIDM), hypertriglyceridemia, obesity, and recurrent pancreatitis presented with three months of worsening bilateral hand pain, described as burning and stabbing. Labs revealed severe DKA and triglycerides >5000 mg/dL. She was started on insulin infusion and IV fluids, leading to resolution of her DKA within 48 hours. However, despite glycemic control, triglyceride levels remained >1700 mg/dL for over a week, and hand pain improved but persisted. Ultimately, after almost two weeks in the unit, when triglyceride decline seemed to regress, evolocumab was administered in the ICU, resulting in a rapid drop in triglycerides and clinical improvement. Finally, her triglycerides fell below 600 mg/dL, and the patient was discharged from the ICU. Interestingly, the patient’s hand pain resolved during admission in parallel with improvement in her hypertriglyceridemia.
Discussion: This case highlights an atypical presentation of hypertriglyceridemia and DKA. The patient’s severe neuropathic hand pain, in the absence of typical DKA symptoms, delayed recognition of the underlying metabolic derangements. Persistent hypertriglyceridemia required prolonged insulin infusion and delayed ICU discharge. Her neuropathy was attributed to chronic hyperglycemia and hypertriglyceridemia, supported by clinical improvement following intensive lipid-lowering therapy, including evolocumab. This case underscores the potential utility of evolocumab as adjunctive therapy in managing refractory hypertriglyceridemia in the ICU setting, particularly when standard insulin therapy proves insufficient. Ultimately, this case demonstrates the insidious nature of DKA and hypertriglyceridemia. While hand pain is an uncommon presenting symptom, it highlights the importance of early recognition and treatment of metabolic decompensation—especially since triglyceride-induced neuropathy is often irreversible.
