Spontaneous pneumomediastinum (SPM) is a relatively uncommon occurrence. Although unlikely, asthma exacerbations can produce enough barotrauma to produce this complication. In cases of SPM, the gas has the opportunity to track between fascial planes, making its way to subcutaneous tissues, usually of the neck and chest, resulting in subcutaneous emphysema (SE). In anomalous situations, this gas can track its way into the retropharyngeal space. This presentation is usually self-limiting, requiring supportive therapy. Severe cases can lead to airway compromise warranting invasive supportive airway maneuvers. Retropharyngeal emphysema, SE, and pneumomediastinum have rarely been described together in the literature. This case provides awareness of these three complications of asthma, while highlighting the need for deliberate chest imaging, including radiograph and non-contrast CT, in patients with severe asthma exacerbations.
Introduction
Covid-19 infection (CI) is known to cause hyperglycemia and insulin resistance in patients with and without diabetes. Prior reports have correlated the degree of hyperglycemia to the severity of the CI. However, not much data is available regarding severe insulin resistance in patients with mild CI who are otherwise asymptomatic and not on steroids.
Case
We report a 48-year old male with type-1 diabetes, asymptomatic CI and renal failure, on dialysis who was admitted with diabetic ketoacidosis (DKA). Patient had refused insulin and hemodialysis treatments for one week and was noted to be confused by staff in his long-term facility. Upon presentation, he was initiated on intravenous (IVIT) insulin infusion therapy and transitioned to subcutaneous (SQ) insulin the following morning. That evening, hyperglycemia worsened (>500 mg/dl), necessitating reinstatement of the IVIT. Hyperglycemia persisted (no excess carbohydrate intake reported by nursing) and IVIT was continued as attempts to change to SQ therapy were unsuccessful. He was dialyzed for two consecutive days after admission and then changed to alternate day schedule. On day 4, hyperglycemia worsened to >500 mg/dl persistently, IVIT rate was increased to 24 units/hr but blood sugars persisted in the >500 range. Work up for evaluating Covid-related inflammation and insulin resistance was sent. After 6 hours of IVIT at 24 U/hr, he was given a relatively higher dose of SQ-insulin (insulin glargine 20 units and insulin lispro 30 units SQ). IVIT rate was gradually tapered based on blood sugars and stopped 6 hours after SQ-insulin was given. Approximately eight hours after receiving SQ-insulin, he was noted to be hypoglycemic, and he received two amps of D-50. His blood sugar stabilized, and he continued to do well subsequently and was maintained on basal-bolus therapy. The on-call nurse confirmed good IV access for the IVIT access line. The IV insulin infusion fluid from bag was sent for analysis which showed that insulin was present in the infusion bag. Inflammatory markers showed high levels of cortisol, ferritin, growth hormone, C-reactive protein and sedimentation rate. Insulin antibodies were also present. D-dimer was normal, and fibrinogen was only mildly elevated.
Conclusion
This is a rare case of severe insulin resistance in a patient with mild Covid-19 infection and underlying type 1 diabetes, who developed severe insulin resistance with poor response to high doses IV insulin. He ultimately responded a combination of high dose subcutaneous insulin and high doses IV insulin infusion therapy with resolution of ketoacidosis and hyperglycemia.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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