MED-23. Unusual cause of refractory nausea and vomiting in a diabetic male.

A 35-year-old diabetic male was admitted to our service for intractable nausea and vomiting, for the fifth consecutive time, within a 2-month period. He had a history of type 1 diabetes mellitus that was under moderate control with the use of mixed insulin twice daily. A few years ago, the patient had developed a stroke on the left side, which resulted in residual weakness. During the time of his current admission, he was ambulatory, but required assistance. In addition to his diabetes, he had also been on treatment for hypertension. During each admission the patient presented with refractory nausea, vomiting, dehydration, acute pre-renal failure and progressive weight loss. He had lost nearly 30 lbs over a span of 2 months. On every occasion, he was treated with vigorous but careful hydration. His renal function would improve and he would be discharged in a stable state. During each visit, the ER attending on duty would dutifully note that the rest of the patient's physical exam was unremarkable; except for signs and symptoms of dehydration, a residual left sided weakness and a recent onset dry gangrene on the right 2nd toe on the paralyzed foot. The circulation on the affected toe did not reveal any significant arterial obstruction. Since there were no signs of inflammation nor was the gangrene symptomatic, but remained confined to the second toe, the surgeons were not eager on removing the toes urgently. The patient had an extensive and thorough workup for nausea and vomiting that included liver function, electrolytes, renal function, upper and lower endoscopy, small bowel series, solid phase gastric emptying study, a bone scan, and a cranial CT. All these tests were negative for any pathology. The patient had a mild leukocytosis (WBC 12,000) and he had pan cultures on several occasions during each successive admission, which all turned out negative. As a last resort, his persistent nausea and vomiting was finally attributed to diabetic gastroparesis but he did not benefit with pro-motility agents. It was very frustrating to see him on the fifth occasion because we were still unable to diagnose the problem or understand the underlying mechanism of his persistent nausea and vomiting. This time it was decided to amputate his toe on the long shot that the toe could be foci of latent infection and the cause for occult bacteremia. Surprisingly, after the amputation, the patient did not return to the hospital anymore for complaints of nausea and vomiting! Follow up visits revealed that he gained the lost weight in a 1-month period and continued to lead his baseline life, without further incidents. The important lesson that we learnt from this case is the fact that even dry gangrene can be a cause for persistent nausea and vomiting. Dry gangrene can be a silent source of a persistent bacteremia, which may not be picked up through routine blood cultures.

Senthil Nachimuthu, MD, and Priyankha Balasundaram, MBBS. Department of Medicine, Tulane University School of Medicine, New Orleans, LA.