Endocrine Abstracts

Introduction: Increasing evidence is emerging that demonstrates the increased prothrombotic risk associated with DKA.¹ We present the case of a child who developed multiple complications which we believe can be explained by his hypercoaguable state.

Case history: A 14-month-old male was admitted in DKA at first diabetic presentation, complicated by cardiovascular shock. Initial blood tests showed blood glucose 80 mmol/l, blood ketones 5.9 mmol/l and venous pH 7.2. He initially responded well to fluid replacement and insulin therapy according to BSPED guidelines, but subsequently developed abdominal distension and fulminant hyperkalaemia (K⁺10.3 mmol/l). Following stabilisation, laparotomy was performed with excision of 106 cm of necrotic jejunum and formation of a duodenal-ileal anastomosis. Post-operative course was complicated by multi-organ failure, development of arterial and venous femoral vasculature thrombosis, high stoma losses and difficult diabetes control. Despite this the patient survived and was eventually able to be discharged home following reversal of his ileostomy.

Conclusions: Acute mesenteric ischaemia (AMI) is a rare complication of DKA. While there are a number of cases described in the adolescent and adult population with long term IDDM^2,3, only two cases have previously been described in the literature of children developing AMI at first diabetic presentation^4,5. These authors differ in their conclusion as to whether non-occlusive ischaemia or thrombotic causes are responsible for AMI in DKA. We believe our report puts a strong case for a thrombotic aetiology, given the level of hyperosmolarity present in our patient and, more significantly, the concurrent development of arterial and venous thromboses. This also provides a platform for discussion of the recommendation in the latest BSPED guideline to give prophylactic anticoagulation in DKA. Furthermore we highlight the diagnosis and management of a rare aspect of DKA which nevertheless has important lessons for the clinician due to its associated morbidity and mortality.

References

1. Carr ME. Diabetes mellitus: a hypercoagulable state. Journal of Diabetes and its Complications 2001 15 (1) 44–54.

2. Chan-Cua S, Jones KL, Lynch FP & Freidenberg GR. Necrosis of the ileum in a diabetic adolescent. Journal of Pediatric Surgery 1992 27 (9) 1236–8.

3. Nicol KK & Davis GJ. An unusual complication of diabetes mellitus: the zebra that became a horse. Southern Medical Journal 1997 90 (1) 83–5.

4. DiMeglio LA, Chaet MS, Quigley CA & Grosfeld JL. Massive ischemic intestinal necrosis at the onset of diabetes mellitus with ketoacidosis in a three-year-old girl. Journal of Pediatric Surgery 2003 38 (10) 1537–9.

5. Ashrafi M, Hashemipour M, Moadab MH, Jamshidi M & Hosseinpour M. Ischemic intestinal necrosis in a five-year-old girl with diabetic ketoacidosis. Archives of Iranian Medicine 2007 10 (4) 529–31.