The Alarming Health issues of Immigrants: Diabetic ketoacido
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The increasing number of refugees and internally displaced people has a profound implication on health, with an outbreak of severe malnutrition and infections preventable by vaccination (such as, poliomyelitis and measles). Children with diabetes and other noncommunicable diseases in this sanitary crisis are not seen as priorities by currents health policies. Policies to fight against disease outbreaks usually outweigh those to control noncommunicable diseases such as diabetes. Herein, is reported the case of an immigrant girl presented with diabetic ketoacidosis and malnutrition, with the aim of raising awareness on the management challenges of diabetic ketoacidosis and acute on chronic malnutrition.

The 14‐year‐old girl, living in a refugee camp, was referred from a district hospital for the management of altered level of consciousness, fever, and hyperglycemia. Fever started 2 weeks prior to consultation for which she received empiric treatment for malaria in a district hospital.

She was also diagnosed with severe acute on chronic malnutrition for which she received ready‐to‐use therapeutic food. The situation was worsened by polyuria, excessive thirst, uncontrolled hyperglycemia, persistent fever and progressive lethargy, necessitating her transfer to the endocrinology unit of another Hospital.

Insulin therapy was started at 0.5 IU/Kg/day with mixed insulin but patient's compliance was poor. She reported loss of sight 7 months ago (3 months after the diagnosis of diabetes). She is the 3rd child in a nonconsanguineous family of 10 children of whom three are alive. They fled their hometown and for the past 4 years have been living in a refugee camp.

On admission, she was lethargic (Glasgow coma scale was 13/15). Her weight was 19 kg (<3rd percentile), her height was 133 cm (<3rd percentile) for a BMI of 10.7 kg/m2, −5.5 SD for age. Her abdomen was distended with no palpable mass. She had vulvovaginal erythema. She had a dry mouth, sunken eyes, mixed signs of dehydration and severe malnutrition (skin pinch went back slowly) and bilateral leucocoria. Urinalysis revealed nitrites (3+), ketones (2+), glycosuria (3+), and culture later on showed growth of E coli.

She was then admitted to the intensive care unit where she received oral rehydration solution for the malnourished (10 mL/kg/hr for 2 hours) followed by 1.5 L/m2/day of normal saline intravenously (IV) and KCL 1.5 g/L (IV) for 24 hours. Rapid‐acting insulin was started 2 hours later with an hourly subcutaneous dose of 0.1 IU/Kg. An antibiotic was also given (ceftriaxone at 50 mg/kg/day) as well as routine de‐worming with a single dose of 400 mg of albendazole.

Rapid‐acting insulin was replaced by multiple injections using neutral protamine Hagedorn insulin (NPH) and actrapid (1IU/kg/day). The day after admission, she developed lower limb edema and abdominal distension without ascites and IV fluids were stopped. The oedema regressed on day 2. On day 3, the F75 was replaced with F100 (100 kcal/100 mL) 130 ml/kg/day and progressive introduction of normal food.

Is Insecurity Responsible for this plight of Immigrants?
1. One of the major consequences of insecurity is food insufficiency. Insecurity is known to severely affect healthcare systems especially in low‐income countries, reducing even the minimal care services available. Because of the political crisis & violence, thousands of people are displaced to neighboring countries & forced to leave their own home behind.
2. In the present case, severe malnutrition (acute and chronic) was probably multifactorial and not exclusively explained by insulin insufficiency.
3. Severe stunting was suggestive of a prolonged insufficient nutritional intake recently worsened by insulin insufficiency.
4. Chronic food insufficiency is known to lead to a reduction of beta cell mass, which might be an accelerating factor of developing diabetes in this patient.
5. Prolonged insecurity, food inadequacy, and unavailability are known to be the foundation of malnutrition in low‐income countries. The latter is the source of high mortality rate in children in these contexts.

Therefore, modification of social conditions of patients living with diabetes is a big challenge, even though insulin is available to ensure their survival. These social conditions can be improved by community interventions such as literacy, patient education in local languages, sustainable micro‐projects for families to increase food access.

Dr. S●●●●●●●●i K●●●●●o and 3 others like this