Hyperglycemia is common in hospitalized patients and associated with adverse clinical outcomes. In hospitalized patients, multiple factors contribute to hyperglycemia, such as underlying medical conditions, pathophysiological stress, and medications. The development of transient insulin resistance is a known cause of hyperglycemia in both diabetic and nondiabetic patients. Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance. Here, we report a case of prolonged course of extreme insulin resistance in a patient admitted with diabetic ketoacidosis (DKA) and acute myocardial infarction (MI). The main purpose of this paper is to review the literature to identify the underlying mechanisms of extreme insulin resistance in a patient with DKA and MI. We will also briefly discuss the different clinical conditions that are associated with insulin resistance and a general approach to a patient with severe insulin resistance. 1. Introduction In hospitalized patients, the development of transient insulin resistance related to different medical conditions such as acute myocardial infarction (MI), sepsis, and medications has been reported. However, the majority of us rarely come across a case of extreme insulin resistance. Here, we report a case of extreme insulin resistance in a patient admitted with diabetic ketoacidosis (DKA) and MI. To the best of our knowledge, our case is the second case report of extreme insulin resistance in a patient presenting with DKA and MI [1]. 2. Case Presentation A 60-year-old Hispanic man with a twenty-year history of type 2 diabetes mellitus presented with 2-day history of generalized weakness and dizziness with home glucose meter reading “High.” Prior to this admission, he was on insulin glargine 20 units subcutaneously at bedtime and replaglinide 1？mg oral three times per day. His fasting blood glucose level at home ranged from 100 to 200？mg/dL. The admission hemoglobin A1c was 8.8%. His past medical history includes hypertension, peripheral vascular disease, dyslipidemia, recent ischemic CVA, and a history of the left 4th and 5th toe amputations for osteomyelitis. Review of systems was essentially negative without chest pain, shortness of breath, fever, cough, dysuria, polyuria, or polydipsia. On exam, vital signs were unremarkable. Weight was 65？kg and body mass index (BMI) was 25. Waist circumference was at 110？cm. Apart from old right facial drop and ptosis, physical exam was also unremarkable.
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