A 20 year old female with a 3 year history of type 1 diabetes presented to the emergency department unresponsive and was diagnosed with severe diabetic ketoacidosis (DKA). She had no other past medical history and was on a basal bolus regime of insulin only. GCS was 7, pH 6.7, HCO3 3.5 mmol/l, ketones 3+ on urinalysis and blood glucose of 43 mmol/l.
She was commenced on fixed rate insulin infusion and IV fluids however also noted to have unequal pupils. She was subsequently intubated and a computed tomography (CT) scan of the head revealed no cerebral oedema or other abnormalities.
Electrolytes remained normal with no evidence of infection and a lumbar puncture was negative for encephalitis and meningitis. The patient remained drowsy and intermittently agitated despite improvement in biochemistry. A repeat CT head was organised revealing several new low attenuation areas in sub-cortical white matter. Subsequent magnetic resonance imaging (MRI) confirmed multiple sub-cortical and deep white matter lesions in keeping with acute disseminated encephalomyelitis (ADEM) and discussion in neurology MDT confirmed the diagnosis.
The episode of DKA resolved with the patient improving clinically, becoming more alert and cognitively intact. A repeat MRI showed improvement in the lesions. The patient recovered fully and was discharged back to her home awaiting a repeat MRI scan and further neurology review in clinic.
ADEM is a rare immune mediated neurological condition that tends to occur following an infection or spontaneously. This is the first known case of ADEM developing secondary to DKA and highlights this unusual presentation in an adult.
07 Nov 2016 - 09 Nov 2016