Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report

Abstract

We present a case of a 29-year-old woman with known Type 1 diabetes who presented with diabetic ketoacidosis (DKA). Despite appropriate treatment and initial improvement, 12 h after initiation of treatment she deteriorated rapidly and developed pulmonary oedema, cerebral oedema and multiple infarctions of the brain and cervical spinal cord. This resulted in spastic quadraparesis and she has remained wheelchair-bound. These complications of DKA are rare and unpredictable. In this case report we discuss the proposed aetiologies of these complications with reference to our case report and highlight the importance of vigilance for early signs of these complications during the treatment of all patients with DKA.

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

“…As with cerebral oedema, the observation that pulmonary oedema usually occurs within a few hours of initiation of treatment has led to the speculation that the complication is iatrogenic and that rapid infusion of crystalloids over a short period of time increases the likelihood of this complication [48]. Elderly patients and those with impaired cardiac function are at particular risk and monitoring of central venous pressure should be considered.…”

Severe diabetic ketoacidosis leading to cardiac failure, pulmonary oedema and spinal cord oedema resulting in tetraplegia

“…During our literature search, we found only one other published case report, by Dixon et al 1 where a patient developed pulmonary and cerebral oedema and also multiple CNS infarctions including the spinal cord. We also found reports of cerebral oedema in children with DKA but without spinal cord oedema 2 3…”

“…The existing theories are limited to cerebral oedema and are mostly in the paediatric diabetic population. However, the pathophysiology behind cerebral oedema and infarction is not clear and there are a few existing theories in the literature, such as: systemic hypotension and hypoxia, rapid changes in serum osmolarity, disseminated intravascular coagulation and thrombosis secondary to dehydration, haemoconcentration and hyperviscosity 1 3 4…”

Stroke as the presenting feature of new onset diabetes in a young man

“…However, DKA associated with stroke in adults remains rare 8. On review of the literature, there are only a small number of case reports regarding the development of ischaemic stroke in adult patients with DKA 8 – 10.…”