(Kiosk 1) Mobility-related Glucose Lability in an Individual with Brittle Type I Diabetes and BRASH Syndrome Admitted for Inpatient Rehabilitation

Case Diagnosis: A 68-year-old male with a history of type I diabetes presented with BRASH (bradycardia, renal failure, atrioventricular nodal blockade, shock, hyperkalemia) syndrome and labile blood glucose levels.

Case Description: The patient presented to an acute care hospital with altered mental status, acute kidney injury, and labile blood sugar. He developed BRASH syndrome, delirium, and recurrent hypoglycemia after multiple acute rehabilitation admissions. Ultimately, he developed complete heart block and diabetic ketoacidosis.

Discussion: Brittle diabetics face unpredictable hypoglycemic and/or diabetic ketoacidosis episodes not attributable to management failure. These patients are constantly at risk for significant metabolic disturbance. Commonly, exercise may increase insulin sensitivity and cause hypoglycemia by increasing the translocation of GLUT4 transporters to the cell membrane during exercise (Mao et al., 2019; Holloszy, 2005; Bird & Hawley, 2017). This patient experienced exacerbated blood glucose lability in settings of increased mobility, supporting this theory.

Setting: Inpatient rehabilitation facility

Assessment/Results: The patient’s glucoses were significantly more labile while at SRH than at acute care despite a similar insulin regimen. The patient’s glucose ranged from 41 - 503 mg/dL (average of 211 mg/dL) at the acute care hospital and ranged from 28 - 607 mg/dL (average of 226 mg/dL) at SRH.  On average, he spent 11.23 minutes/day in therapy at acute care and 108.3 minutes/day at SRH.

Conclusion: A 68-year-old male with brittle type 1 diabetes and BRASH syndrome experienced increasingly labile blood glucose levels correlated with increased physical activity while admitted at SRH. Patients with brittle diabetes may need closer glucose level management while at inpatient rehabilitation due to increases in their mobility levels.