A case of spontaneous pneumomediastinum and diabetic ketoacidosis in patient with diabetes mellitus which was undiagnosed before
Doo-Man Kim1, Sunwoo Kim2 & Soonjib Yoo3
Introduction: Pneumomediastinum is a rare complication of diabetic ketoacidosis (DKA). The pathophysiology of DKA commonly associated with changes in pressure gradients in the pulmonary alveoli secondary to vomiting and/or Kussmaul respiration. We report a 21-year-old male with DKA who have no history of diabetes mellitus before and was found to have pneumomediastinum and subcutaneous emphysema.
Case: A 21-year-old male without previous history of diabetes mellitus was admitted via ER with complaints of general weakness and throat pain on swallowing. His BMI was 19.6 kg/m2, white blood count 18.480/mm3, haemoglobin 16.5 g/dl, BUN/Cr 23.5/2.8 mg/dl. His serum glucose was 771 mg/dl, sodium/potassium/chloride/bicarbonate 138/45/92/15.2 meq/l. His calculated anion gap was 31 with an arterial pH of 7.31. Serum ketone was elevated to 5.7 mmol/l. Initial chest radiograph showed mediastinal air along left cardiac border but this finding was ignored by ER doctor. On 2nd day of admission subcutaneous emphysema was detected by physical examination, and initial chest X-ray film was re-examined. After then chest CT and gastrograffin swallowing study was followed. Chest computerized tomography (CT) demonstrated the air in the soft tissues of the neck, nasopharynx and within the anterior mediastinum. There was no evidence of esophageal tear or extravasation of gastrograffin into the mediastinum.
His serum C-peptide was 0.7 ng/ml and HbA1c 16.9%. Test about anti-GAD antibody and anti-islet cell antibody showed negative results.
His pneumomediastinum and subcutaneous emphysema resolved spontaneously during the admission with oxygen therapy using facial mask, and he was discharged in improved condition with the prescription of multiple daily insulin injection.