Endocrine Abstracts

JOINT2767

Introduction: Pneumomediastinum is an entity defined with presence of free air in the mediastinum cavity. It is usually due to a trauma but it can occur spontaneously. Association with diabetic ketoacidosis (DKA) has been reported in few cases. Herein, we present the case of a patient who was diagnosed with DKA accompanied with spontaneous pneumomediastinum.

Case presentation: A 17-year-old male patient, with no medical history was admitted in our hospital in January 2025 for acute vomiting and general fatigue. He didn’t report any history of trauma. Respiratory rate was 33 breaths/minute, heart rate was 121 beats/minute, blood pressure was 116/81mmHg. The patient was apyretic. Subcutaneous crepitus on chest and neck was found. Blood glucose was 5.3 g/l. Arterial gas showed pH of 6.85, HCO3- of 2.6, pCO2 of 15.1, pO2 of 128.8. The chest abdomen and pelvis scan demonstrated pneumomediastinum, subcutaneous emphysema and pneumoperitoneum. Severe DKA was confirmed. The patient received hydration with normal saline and intravenous rapid insulin infusion with relay to subcutaneous insulin. The pneumomediastinum was treated conservatively. The evolution was favorable. There was no dyspnea neither chest pain. Respiratoy rate was normal. A good glycemic control was obtained with basal-bolus insulin. A chest X-ray of control 13 days after the DKA was normal.

Comments and Conclusions: Spontaneous pneumomediastinum is a rare condition, first reported by Hamman in 1939. Pathophysiology was decribed by Maklin as an increase in intralveolar pressure, followed by alveolar rupture. This barotrauma can be the result of severe vomiting and Kussmaul breathing in DKA. Air dissects through the bronchovascular sheath into the mediastinum. It can also dissect through other serous structures, subcutaneous tissue and peritoneal cavity. It is generally a benign entity with a good prognosis. Spontaneous resolution of the pneumomediastinum was found in most reported cases. Careful attention to this particular condition is needed espacially by emergency physicians to avoid under-diagnosis.