SUN-260 - A Fatal Flu-Triggered Metabolic Storm with Myocardial Injury and Shock

Introduction:
Influenza, though typically self-limited, can precipitate severe metabolic and cardiovascular complications in individuals with diabetes. Impaired immunity and dysregulated glycemia increase susceptibility to poor outcomes, including DKA, ICU admission, and death [1,2]. Viral illness heightens resistance and accelerates ketosis in poorly controlled diabetes [3,4]. Unvaccinated individuals face greater risk of severe influenza, myocarditis, and multiorgan failure [5]. Multiple studies consistently support the importance of annual influenza vaccination, particularly in diabetics [2,7,8].

Here, we present a case of profound influenza-driven metabolic decompensation in a diabetic patient overlapped by myocardial dysfunction and multifactorial shock.

Case Presentation:
A 56-year-old man with poorly controlled type 2 diabetes (HbA1c >14%) presented with fever, dyspnea, and glucose >500 mg/dL.On arrival, his temperature was 39.2 °C, heart rate 158 bpm (irregular), BP 185/97 mmHg, and respiratory rate 30 brpm. Labs revealed glucose 541 mg/dL, pH 6.94, HCO₃⁻ 5 mEq/L, anion gap 31, lactate 4.7 mmol/L, troponin 68 ng/L, WBC 39 × 10³/μL. Imaging showed multifocal pneumonia. DKA protocol and antibiotics for sepsis were initiated.

Soon, he developed atrial fibrillation, respiratory failure requiring intubation, and vasopressor-dependent shock. Serial troponins peaked at 22,000 ng/L with new lateral T-wave inversions on an EKG. Echocardiography revealed a LVEF of 45–50% with mild global and posterior-septal hypokinesis and a small pericardial effusion, consistent with mixed ischemic/inflammatory myocardial injury. Blood cultures grew Klebsiella pneumoniae. Despite maximal hemodynamic and ventilatory support in ICU, he developed refractory acidosis and pulseless electrical activity, dying within 36 hours.

Discussion:
This case demonstrates how influenza can precipitate DKA complicated by myocardial injury and septic shock [3,4,6]. The viral stress response induced counter-regulatory hormone surges, while systemic inflammation and hypoxia led to shock [3,6]. Elevated troponins suggest overlapping type 2 myocardial infarction and myocarditis [6]. Secondary bacterial pneumonia likely compounded shock and respiratory failure [4]. Lack of vaccination and delayed care likely worsened outcomes [5,7]. Large cohort and meta-analytic data confirm influenza vaccination reduces hospitalizations, cardiovascular events and mortality in diabetes [1,2,8].

Conclusion:
Influenza can rapidly destabilize glycemic control, leading to metabolic collapse and multiorgan failure. Marked troponin elevation in DKA should prompt evaluation for myocarditis or type 2 MI. This case underscores the need for early influenza recognition, metabolic optimization, and routine vaccination to prevent fatal outcomes in high-risk diabetic patients.

References: 8

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