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Acanthosis Nigricans and Diabetic Ketoacidosis

Acanthosis nigricans is a cutaneous lesion expressed as brown hyperpigmented and velvety plaques seen in body folds such as the neck and axilla. This condition is frequently accompanied by insulin resistance and hyperinsulinemia, but it is rarely associated with diabetes (1,2). Although diabetic ketoacidosis may develop in patients with type II diabetes when they experience severe metabolic stress (3), it usually occurs only in individuals whose circulating insulin is virtually absent. Theoretically, patients with acanthosis nigricans are hyperinsulinemic and are not likely to develop diabetic ketoacidosis. A 14-year-old boy presented to the emergency department of the Taichung Veteran General Hospital, Taichung, Taiwan, with a chief complaint of the progressive development of polyuria, polydipsia, and general weakness for 2 weeks, associated with a shortness of breath for 3 days. He complained of nausea and vomiting, but had no abdominal pain. He had lost 4 kg of body weight over several weeks. He denied nasal congestion, sore throat, dysuria, or diarrhea. His father, 44 years of age, had had type II diabetes for 8 years. His mother, 40 years of age, and one sister, 10 years of age, were in good health. On examination, the boy was 170 cm in height and 89 kg in weight. Brown hyperpigmentation of skin folds over the neck, especially the collar region, and axilla was present. Initial serum biochemical data showed hyperglycemia (serum glucose concentration, 30.59 mmol/1) and the presence of ketones. Metabolic acidosis was noted by arterial blood gas. He was admitted and treated for diabetic ketoacidosis. His condition improved in 24 h with intravenous fluids and insulin. A skin biopsy of the neck confirmed the diagnosis of acanthosis nigricans. His serum Cpeptide values before and 3 and 6 min after the injection of 1 mg glucagon were 1.03, 2.81, and 2.58 nmol/1, respectively. His daily insulin requirement was 78 U before he was discharged.