Myocardial injury in a pediatric patient with diabetic ketoacidosis

Abstract

Rationale: Diabetic ketoacidosis (DKA) can cause several complications. Among them, cardiac complications are the most fatal and difficult to detect. Cardiac markers are prognostic factors for morbidity and mortality in adult patients with DKA. But, there have been very few discussed cases in pediatrics. We report a case of severe DKA in child with elevated cardiac enzymes and prolonged QT interval. Patient concerns: A 12-year-old girl admitted by nausea, vomiting, and lethargy for 1 day. Diagnoses: Her blood sugar level was initially undetectable by the capillary blood glucose meter, and blood gas analysis showed severe DKA with elevated cardiac enzymes and prolonged QT interval. Interventions: The patient was admitted to hospital and intensive intravenous fluid and regular insulin infusion were administered. Outcomes: After 5 days of supportive care, the patient was fully recovered, discharged, and followed up in an outpatient clinic. Lessons: Since the relationship between DKA and myocardial injury has not been clearly elucidated, pediatricians and emergency physicians should remain careful throughout the recovery time as it can lead to life-threatening conditions in various courses.

Markedly elevated troponin and NT-proBNP and myocardial dysfunction in an adolescent with severe diabetic ketoacidosis: A case report

“…Interestingly, a recently published study reported a significant increase in troponin and NT-proBNP levels and QTs prolongation in a 12-yr-old patient with moderate DKA (pH 7.11; HCO 3 7.1 mEq/L). This patient was slightly younger than ours, had uncontrolled T1D (5 yr duration), and most importantly, had a fever and high inflammatory markers during DKA, all of which may contribute to myocardial injury ( 7 ).…”

“…This is a novel case of severe DKA associated with mild myocardial dysfunction and disproportionately elevated NT-proBNP and troponin levels in a newly diagnosed T1D in an adolescent. As mentioned earlier, to the best of our knowledge, only three cases of myocardial injury have been observed in pediatric patients with severe new-onset DKA ( 5 , 6 , 7 ). In all of the above cases, patients experienced a fulminant clinical course of the disease with severe complications, while troponin levels were mildly elevated.…”

“…In addition, positive troponin levels during DKA in adults are associated with long-term adverse cardiac events ( 4 ). In children, only three reports have suggested an association between severe DKA and increased troponin levels ( 5 , 6 , 7 ).…”

Serum Troponin I Level in Children with Diabetic Ketoacidosis

“… 5 , 6 However, there are few case reports regarding myocardial damage in pediatric DKA patients. 7 , 8 In addition, some investigations have concluded that elevated troponin levels during DKA increase future mortality risk. 9 …”

“…The available studies and case reports on myocardial involvement in the pediatric age group are rare. Shim et al 7 reported a 12-year-old girl with an elevated troponin level and myocardial injury during severe DKA. The changes were entirely resolved after 5 days of supportive care, and she was discharged without sequelae.…”