Multiple Ischemic Infarctions, Pulmonary Edema, and Acute Renal Failure During an Episode of Diabetic Ketoacidosis in an Adult

Abstract

The morbidity and mortality associated with diabetic ketoacidosis (DKA) often refl ects the precipitating events, such as myocardial infarction. However, DKA can trigger a systemic infl ammatory response with the potential for multiple complications. This 30-year-old woman with type 1 diabetes mellitus improved within 48 hours of admission with a standard DKA treatment protocol. However, subsequent chest X-rays revealed bilateral infi ltrates consistent with pulmonary edema; she then developed fever, hypotension, and acute-on-chronic renal failure. An altered level of consciousness prompted evaluation with neuroimaging, which revealed ischemic infarcts in the right frontal, parieto-occipital, and temporal cortices and cerebellum correlating with a leftsided hemiparesis. This case illustrates the potential complexity in the pathogenesis and management of patients with DKA. This patient likely had a systemic infl ammatory response syndrome with multiorgan failure during this episode of DKA. Patients with DKA need risk stratifi cation for comorbid diseases on presentation and attention to vital signs, especially unexplained fever, evolving neurologic symptoms, and respiratory symptoms during the hospital course. This information can help dictate the time course for treatment; standard treatment protocols for patients with DKA may create a false sense of security in complex patients.