The onset of fulminant type 1 diabetes mellitus is sometimes accompanied by sudden death or cardiac arrest. The aim of this study was to determine the risk factors for the development of these conditions at the onset of fulminant type 1 diabetes mellitus.
We conducted a search of the literature on fulminant type 1 diabetes and sudden death or cardiac arrest published up to 2012 in PubMed and Ichushi (a Japanese article database), and a questionnaire survey was administered to the authors of the articles and to diabetes specialists affiliated to the Japan Diabetes Society. We analyzed the clinical data at disease onset of 17 patients with fulminant type 1 diabetes mellitus who experienced sudden death or cardiac arrest, and those of 257 patients who did not develop these conditions.
Patients with sudden death or cardiac arrest were younger, had a higher rate of impaired consciousness, more severe acidosis, hyperglycemia, hyponatremia, hyperkalemia, and hypochloremia, a higher serum blood urea nitrogen level, a higher serum creatinine level, and a higher plasma osmolality level than the other patients. In multiple logistic regression analyses, plasma glucose level was positively associated with sudden death or cardiac arrest. Receiver operating characteristic curve analyses showed that patients with a plasma glucose level over 1000 mg/dl (55.5 mmol/l) were at a high risk of cardiac arrest.
Severe metabolic derangement, especially a high plasma glucose level, is associated with sudden death or cardiac arrest at the onset of fulminant type 1 diabetes mellitus.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Atkinson MA, Eisenbarth GS, Michels AW. Type 1 diabetes. Lancet. 2014;383:69–82.
Greenbaum CJ, Cuthbertson D, Krischer JP. Type I diabetes manifested solely by 2-h oral glucose tolerance test criteria. Diabetes. 2001;50:470–6.
Hanafusa T, Imagawa A. Fulminant type 1 diabetes: a novel clinical entity requiring special attention by all medical practitioners. Nat Clin Pract Endocrinol Metab. 2007;3:36–45.
Imagawa A, Hanafusa T, Uchigata Y, Kanatsuka A, Kawasaki E, Kobayashi T, Shimada A, Shimizu I, Toyoda T, Maruyama T, Makino H. Fulminant type 1 diabetes: a nationwide survey in Japan. Diabetes Care. 2003;26:2345–52.
Cho YM, Kim JT, Ko KS, Koo BK, Yang SW, Park MH, Lee HK, Park KS. Fulminant type 1 diabetes in Korea: high prevalence among patients with adult-onset type 1 diabetes. Diabetologia. 2007;50:2276–9.
Sayama K, Imagawa A, Okita K, Uno S, Moriwaki M, Kozawa J, Iwahashi H, Yamagata K, Tamura S, Matsuzawa Y, Hanafusa T, Miyagawa J, Shimomura I. Pancreatic beta and alpha cells are both decreased in patients with fulminant type 1 diabetes: a morphometrical assessment. Diabetologia. 2005;48:1560–4.
Sekine N, Motokura T, Oki T, Umeda Y, Sasaki N, Hayashi M, Sato H, Fujita T, Kaneko T, Asano Y, Kikuchi K. Rapid loss of insulin secretion in a patient with fulminant type 1 diabetes mellitus and carbamazepine hypersensitivity syndrome. JAMA. 2001;285:1153–4.
Uto Y, Uto K, Teno S, Isono K, Omori Y. A case of fulminant type 1 diabetes mellitus detected after cardiac arrest due to diabetic ketoacidosis. J Japan Diab Soc. 2002;45:689–93.
Shigeta M, Obana M, Iwamoto K, Ichikawa A, Nakata K, Hoshi D, Koshikawa Y, Nozaki H, Suzuki T, Osone Y, Akizuki T, Matsuoka Y, Shibayama K. Two cases of fulminant type 1 diabetes mellitus. Kawasakishi Ishikai Igakkaishi. 2003;20:118–24 (in Japanese).
Nakagawa M, Abe S, Tsutsumi R, Goto D, Tsutsu N, Umeno J, Inou T. A case of fulminant type 1 diabetes mellitus suffered cardiopulmonary arrest. J Japan Diab Soc. 2004;47:671 (in Japanese).
Goto H, Abiru H, Iino M, Tamaki K. An autopsy case of fulminant type 1 diabetes mellitus. Nihon Hoigaku Zassi. 2005;59:201 (in Japanese).
Fukushima T, Abiru N, Moriuchi A, Fukushima K, Kuwahara H, Uotani S, Yamazaki H, Eguchi K, Kobayashi M, Kita A, Kawasaki E. Fulminant type 1 diabetes mellitus with cardiopulmonary arrest. J Japan Diab Soc. 2005;48:371 (in Japanese).
Kobayashi T, Isomine S, Goto M, Sato M, Kanazawa T, Sakaida K, Iwaoka H. A case of fulminant type 1 diabetes with ECG changes in the first trimester of pregnancy. J Jpn Soc Intensive Care Med. 2005;12:25–30 (in Japanese).
Tanaka S, Nishida Y, Aida K, Maruyama T, Shimada A, Suzuki M, Shimura H, Takizawa S, Takahashi M, Akiyama D, Arai-Yamashita S, Furuya F, Kawaguchi A, Kaneshige M, Katoh R, Endo T, Kobayashi T. Enterovirus infection, CXC chemokine ligand 10 (CXCL10), and CXCR3 circuit: a mechanism of accelerated beta-cell failure in fulminant type 1 diabetes. Diabetes. 2009;58:2285–91.
Shibasaki S, Imagawa A, Tauriainen S, Iino M, Oikarinen M, Abiru H, Tamaki K, Seino H, Nishi K, Takase I, Okada Y, Uno S, Murase-Mishiba Y, Terasaki J, Makino H, Shimomura I, Hyoty H, Hanafusa T. Expression of Toll-like receptors in the pancreas of recent-onset fulminant type 1 diabetes. Endocr J. 2010;57:211–9.
Sato S, Honkura K, Yamashita R, Takahashi M, Seino J, Kaise K, Tanigawa T. Two cases of fulminant type 1 diabetes mellitus suffered cardiac complication within early days of onset. J Japan Diab Soc. 2010;53:S207 (in Japanese).
Kunieda T, Murayama M, Koga M, Hanatate F, Hayashi M, Yamakita N, Yasuda K. A case of ischemic stricture of the small intestine due to cardiac arrest caused by diabetic ketoacidosis in fulminant type 1 diabetes. J Japan Diab Soc. 2011;54:356–60 (in Japanese).
Maekawa Y, Yara T, Nashiro K, Masuda F, Kowatari M, China Y, Yamashiro A, Kinjyo M, Shiroma I. A survived case of fulminant type 1 diabetes after cardiac arrest with hyperkalemia and ST elevation. J Japan Diab Soc. 2011;54:359 (in Japanese).
Aida K, Nishida Y, Tanaka S, Maruyama T, Shimada A, Awata T, Suzuki M, Shimura H, Takizawa S, Ichijo M, Akiyama D, Furuya F, Kawaguchi A, Kaneshige M, Itakura J, Fujii H, Endo T, Kobayashi T. RIG-I- and MDA5-initiated innate immunity linked with adaptive immunity accelerates beta-cell death in fulminant type 1 diabetes. Diabetes. 2011;60:884–9.
Inokuchi R, Matsumoto A, Odajima H, Shinohara K. Fulminant type 1 diabetes mellitus. BMJ Case Rep. 2012. doi:10.1136/bcr-2012-006560.
Hiramatsu S, Komori K, Mori E, Ogo A, Maruyama S, Kato S. A case of fulminant type 1 diabetes mellitus accompanied by myocarditis. Endocr J. 2011;58:553–7.
Iwaoka T. A case of fulminant type 1 diabetes with transiently positive anti-GAD antibodies. Endocr J. 2003;50:225–31.
Mizutani T, Yoshimoto T, Kaneko R, Ishii A. Diagnosis of fulminant type 1 diabetes mellitus in an autopsy case with postmortem changes. Leg Med. 2011;13:250–3.
Ro A, Hisashi Y, Kageyama N, Tanifuji T, Hayashi K, Fukunaga T, Fujita MQ. Two autopsy cases of sudden death in adolescent by fulminant type 1 diabetes mellitus. Houibyouri. 2006;12:22–6 (in Japanese).
Bird S. Failure to diagnose: diabetic ketoacidosis. Aust Fam Physician. 2010;39:867–8.
Ohashi R, Hasegawa G, Naito M. An autopsy case of fulminant type 1 diabetes complicated by Reye syndrome. Proc Jpn Soc Pathol. 2005;94:342 (in Japanese).
Tamaki E, Doi M, Masuda R, Kato Y. A case of fulminant type 1 diabetes occurred in late pregnancy. Kanto J Obst Gynec. 2007;44:187 (in Japanese).
Imagawa A, Hanafusa T, Awata T, Ikegami H, Uchigata Y, Osawa H, Kawasaki E, Kawabata Y, Kobayashi T, Shimada A, Shimizu I, Takahashi K, Nagata M, Makino H, Maruyama T. Report of the Committee of the Japan Diabetes Society on the Research of Fulminant and Acute-onset Type 1 Diabetes Mellitus: new diagnostic criteria of fulminant type 1 diabetes mellitus. J Diabetes Investig. 2012;3:536–9.
Hindle EJ, Rostron GM, Gatt JA. The diagnostic value of glycated haemoglobin levels in post-mortem blood. Ann Clin Biochem. 1985;22:144–7.
Kashiwagi A, Kasuga M, Araki E, Oka Y, Hanafusa T, Ito H, Tominaga M, Oikawa S, Noda M, Kawamura T, Sanke T, Namba M, Hashiramoto M, Sasahara T, Nishio Y, Kuwa K, Ueki K, Takei I, Umemoto M, Murakami M, Yamakado M, Yatomi Y, Ohashi H. International clinical harmonization of glycated hemoglobin in Japan: from Japan Diabetes Society to National Glycohemoglobin Standardization Program values. J Diabetes Investig. 2012;3:39–40.
Chiou CC, Chung WH, Hung SI, Yang LC, Hong HS. Fulminant type 1 diabetes mellitus caused by drug hypersensitivity syndrome with human herpesvirus 6 infection. J Am Acad Dermatol. 2006;54:S14–7.
Nagaoka T, Terada M, Miyakoshi H. Insulin-dependent diabetes mellitus following acute pancreatitis caused by herpes simplex virus; a case report. J Japan Diab Soc. 2001;44:335–40 (in Japanese).
Nishida W, Hasebe S, Kawamura R, Hashiramoto M, Onuma H, Osawa H, Makino H. A case of fulminant type 1 diabetes associated with high titer of coxsackie B3 virus antibody. J Japan Diab Soc. 2005;48(suppl 1):A23–7 (in Japanese).
Sano H, Terasaki J, Tsutsumi C, Imagawa A, Hanafusa T. A case of fulminant type 1 diabetes mellitus after influenza B infection. Diabetes Res Clin Pract. 2008;79:e8–9.
Onuma H, Tohyama M, Imagawa A, Hanafusa T, Kobayashi T, Kano Y, Ohashi J, Hashimoto K, Osawa H, Makino H. High frequency of HLA B62 in fulminant type 1 diabetes with the drug-induced hypersensitivity syndrome. J Clin Endocrinol Metab. 2012;97:e2277–81.
Shimada A, Maruyama T. Encephalomyocarditis-virus-induced diabetes model resembles “fulminant” type 1 diabetes in humans. Diabetologia. 2004;47:1854–5.
The other member of the Japan Diabetes Society Committee on Type 1 Diabetes Mellitus Research is Seiho Nagafuchi (Department of Medical Science and Technology, Graduate School of Medical Sciences, Kyushu University). The authors express their sincere gratitude to Dr. Kazuro Kaise, Dr. Satsuki Niitsuma, Dr. Ayako Ro, Dr. Kazuaki Shinohara, and all diabetes specialists affiliated to the Japan Diabetes Society for answering the questionnaire.
Conflict of interest statement
Toshiaki Hanafusa received honoraria for lectures from Ono Pharmaceutical, Mitsubishi Tanabe Pharma, and Sumitomo Dainippon Pharma. Hiroshi Ikegami received honoraria for lectures from Novo Nordisk Pharmaceuticals Industries, Inc., Sumitomo Dainippon Pharma, and Kowa Company, and scholarship grants from Ono Pharmaceutical and Novo Nordisk Pharmaceuticals Industries, Inc. Yumiko Kawabata received scholarship grants from Ono Pharmaceutical and Novo Nordisk Pharmaceuticals Industries, Inc. Other authors declare that they have no conflict of interest.
Human rights statement and informed consent
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or a substitute for it was obtained from all patients before they were included in the study.
For the consultation of the Japan Diabetes Society Committee on Type 1 Diabetes Mellitus Research.
About this article
Cite this article
Baden, M.Y., Imagawa, A., Iwahashi, H. et al. Risk factors for sudden death and cardiac arrest at the onset of fulminant type 1 diabetes mellitus. Diabetol Int 7, 281–288 (2016). https://doi.org/10.1007/s13340-015-0247-6
- Fulminant type 1 diabetes mellitus
- Sudden death
- Cardiac arrest
- Risk factors