Page 101 - JSOM Summer 2023

Management of Type 3c Diabetes
in an Elite Tactical Athlete

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Jacob J. Avilla, BS *; Caitlyn M. Rerucha, MD, FAAFP ;
Collin Hu, DO, FAAFP 3

ABSTRACT
The presentation of Type 3c diabetes is atypical, accounting with cyst involving more than 50% of pancreas, no abscess,
for 0.5–1% of all types of diabetes. Combining this with the non-obstructed biliary tree, a 5-mm common bile duct, and
healthy Special Operations community is even more profound. gallbladder without wall thickening or gallstones. Surgical
A 38-year-old active-duty male in Special Operations devel- management was not required. Medications included lisino-
oped acute abdominal pain and vomiting while deployed. He pril 5mg and sertraline 25mg for a diagnosis of posttraumatic
was diagnosed with severe acute necrotizing pancreatitis sec- stress disorder (PTSD). He was abstinent from alcohol for 3
ondary to Type 3c diabetes, and the management of his condi- weeks prior to initial symptom onset. He deployed prior to
tion became increasingly difficult. This case highlights Type 3c the availability of the COVID-19 vaccine and was thus un-
diabetes and the complexity of formulating a comprehensive vaccinated; subsequent COVID-19 polymerase chain reaction
treatment plan for a tactical athlete. (PCR) and antibody testing were negative. He did not receive
any other vaccinations within 6 weeks prior to deployment.
Keywords: tactical; type 3c diabetes; abdominal pain; pan- Pre-deployment triglycerides were 50mg/dL and HbA1c was
creatitis; athlete; special operations 5.4%. His family history is notable for a younger brother di-
agnosed with acute pancreatitis at 20 years old.
While hospitalized, blood glucose was managed with slid-
Introduction
ing scale insulin aspart while he transitioned from nothing
Acute pancreatitis and diabetes mellitus (DM) are commonly by mouth (NPO) to a regular diet with improvements in his
managed medical conditions, yet little evidence exists to guide abdominal pain. He had no insulin requirement at discharge.
DM management that results from pancreatitis and the result- Three months post-hospitalization, his HbA1c was 6.4%. He
ing loss of pancreatic exocrine function. The authors describe worked with a multidisciplinary team under a supervised re-
a case of Type 3c diabetes in an elite tactical athlete caused by turn-to-duty progression, including a sports dietician, phys-
a single episode of acute idiopathic pancreatitis. ical therapist, and strength and conditioning coach. After 3
months, he returned to light running and weight training sev-
eral days per week. At 4 months post-hospitalization, his pan-
Case Presentation
creatic necrosis stabilized with no evidence of intra-abdominal
The patient is a 38-year-old, active-duty, Russian-born male infection, and he was started on pancrealipase by gastroenter-
from Kazakhstan, who is a Soldier in the Special Operations ology for pancreatic enzyme insufficiency.
community. He developed an inability to retain any food or
fluids by mouth with several episodes of non-bilious, non- At 6 months post-hospitalization, the Soldier reported acute
bloody emesis and acute onset of diffuse abdominal pain onset of blurred vision, polyuria, and polydipsia. Random
while deployed. He was evaluated in the emergency depart- glucose readings on a home glucometer were elevated to
ment (ED) of a host nation hospital and admitted for altered >300mg/dL. HbA1c was repeated and found to be 11.4%.
mental status and uremia requiring hemodialysis (creatinine Work-up for diabetic ketoacidosis was negative. Additionally,
9mg/dL, baseline 0.8mg/dL). He was finally diagnosed with se- his C-peptide and insulin levels were low. Endocrinology diag-
vere acute necrotizing pancreatitis. Upon stabilization, he was nosed the patient with Type 3c DM, pancreatogenic diabetes
transferred to Landstuhl Regional Medical Center, Landstuhl, mellitus.
Germany, and then to the intensive care unit at Walter Reed
National Military Medical Center, Bethesda, MD. His 4-week As a result of his new diagnosis, he was started on nine units of
hospitalization was complicated by hospital-acquired C. diffi- insulin glargine at bedtime with continuous glucose monitor-
cile colitis, ileus, and splenic vein thrombosis. ing. After 6 weeks on insulin, HbA1c decreased to 8.0%. During
this period, he reported two episodes of exercise-related hypo-
A thorough work-up for the underlying etiology of his pan- glycemia per week that occurred during strength training or
cre atitis was unrevealing. Multiple abdominal computed after running. Insulin was discontinued, and he started a trial
tomography (CT) scans and magnetic resonance cholangio pan- of empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2)
creatographies (MRCPs) showed diffuse pancreatic necrosis inhibitor, which acts by stopping the reuptake of glucose into
*Correspondence to Jacob.Avilla@usuhs.edu
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1 Jacob J. Avilla is a medical student at the Uniformed Services University of Health Sciences, Bethesda, MD. Dr Caitlyn M. Rerucha and
3 Dr Collin Hu are family medicine physicians and assistant professors at the Uniformed Services University of Health Sciences, Bethesda, MD.
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