Introduction: Diabetic Ketoacidosis (DKA) is a medical emergency and major cause of mortality in children with type 1 diabetes (T1D). Careful evaluation is needed to identify expected and more unusual complications of DKA.
Case report: A 16 year old male with poorly controlled T1D presented with severe DKA; he reported excessive vomiting and had severe abdominal pain. He informed taking Ecstasy (3,4-methylenedioxymethamphetamine; MDMA) twice in the preceding 72 h. Investigations revealed severe acidosis (pH 6.84), pre-renal failure (serum creatinine 137 μmol/l) and glycated Haemoglobin (HbA1c) >196 mmol/mol (>20%). X-rays excluded sub-diaphragmatic free air, but showed pneumomediastinum (PM) and subcutaneous emphysema of neck; CT demonstrated no convincing oesophageal tear. Urine toxicology showed MDMA traces and cannabinoids (patient later confided regular cannabis use). DKA management and a conservative surgical approach for possible oesophageal perforation were concurrently undertaken: nil by mouth (NBM); intravenous antibiotics for presumed mediastinitis; total parenteral nutrition (TPN) to promote oesophageal healing and prevent catabolism whilst NBM. Insulin titrated to glucose content of TPN, following DKA resolution. Enteral feeds re-started a week later, after contrast study demonstrated normal oesophageal appearances and no oesophageal leak. Patient and parents underwent intense diabetes re-education and patient referred to local addictions service. HbA1c improved to 115 mmol/mol (12.6%) by Day 12 with adequate insulin therapy.
Discussion: PM is a rare complication of DKA. Case reports describe PM following MDMA ingestion (without vomiting) possibly related to Valsalva manoeuvre during extreme physical exertion such as strenuous dancing. Severe vomiting can generate high intra-thoracic pressures (possibly intensified by recreational drug use) with alveolar over-distension and rupture, causing air tracking along bronchovascular bundles and PM. Hammans syndrome refers to PM with subcutaneous emphysema and has excellent prognosis. Effort rupture of the oesophagus (Boerhaaves syndrome) has a high mortality from mediastinitis, necrosis and sepsis; distinguishing between the two entities can be challenging.
Learning points: Spontaneous PM is a rare complication of DKA.
Careful assessment needed in DKA patients with epigastric, retrosternal, neck or chest pain
DKA admission provides opportunity for re-education and improved glycaemic control; adolescents and families benefit from holistic, open dialogue.
27 - 29 Nov 2019
British Society for Paediatric Endocrinology and Diabetes