Loading

Journal of Endocrinology, Diabetes and Obesity

A Case of Recurrent Cerebral Oedema in Diabetic Ketoacidosis

Case Report | Open Access Volume 1 | Issue 1 |

  • 1. Department of Endocrinology, Children’s University Hospital, Temple Street, Dublin, Ireland
  • 2. Department of Radiology, Children’s University Hospital, Temple Street, Dublin, Ireland
+ Show More - Show Less
Corresponding Authors
Nuala P Murphy, Department of Endocrinology, Children’s University Hospital, Temple Street, Dublin, Ireland, USA, Tel: 00353 1 878 4200; Fax: 00353 1 874 8355.
Abstract

A 7-year-old girl presented with new onset type 1 diabetes, with moderate diabetic ketoacidosis. She developed clinical and radiologically confirmed cerebral oedema managed with mannitol. Despite slow normalisation of biochemical parameters and marked clinical improvement, she had a further episode of symptomatic cerebral oedema 50 hours following presentation.

Keywords

•    Diabetic ketoacidosis
•    Cerebral edema

Citation

Hawkes CP, Laffan EE, Murphy NP (2013) A Case of Recurrent Cerebral Oedema in Diabetic Ketoacidosis. J Endocrinol Diabetes Obes 1(1): 1001.

ABBREVIATIONS

DKA: Diabetic Ketoacidosis; GCS: Glasgow Coma Scale; PICU: Pediatric Intensive Care Unit

INTRODUCTION

The incidence of diabetic ketoacidosis (DKA) at diagnosis of type one diabetes varies from 15 to 70%, and is more common at presentation in younger children, newly diagnosed (compared to established) diabetes, and those in lower socioeconomic classes [1]. Cerebral oedema is a significant cause of mortality in children with DKA and close observation for the development of this complication is required. We present the case of a 7 year old girl who developed a recurrence of symptomatic cerebral oedema despite apparent clinical recovery from her initial episode.

CASE REPORT

A 7 year-old previously well girl presented to the Emergency Department with a one week history of polydipsia and polyuria. She also had a 3 day history of vomiting and abdominal pain. On arrival, she was sleepy but rousable and had a Glasgow Coma Scale (GCS) score of 15/15. Her respiratory rate was 36, heart rate was 140, and capillary refill time was 3 seconds. Her venous blood results were consistent with moderate diabetic ketoacidosis (Glucose = 28.6mmol/L (515mg/dL), Ketones = 3.9mmol/L, pH = 7.12, pCO2 = 3.1kPa, HCO3 - = 9.2mmol/L, Base Excess = -20.3, Corrected Sodium = 130mmol/L, Potassium = 3.9mmol/L, Urea = 9.8mmol/L, Creatinine = 83umol/L). She was managed as per accepted guidelines [1]. She initially received 10ml/kg 0.9% NaCl over 30 minutes and was then maintained on 0.9%NaCl to correct an 8% deficit over 48 hours, with the inital bolus subtracted from fluid replacement. Insulin infusion was deferred for 60 minutes. Forty five minutes after starting intravenous fluids and prior to commencing insulin, she became acutely disorientated, confused and aggressive. This was followed by lethargy and poor responsiveness over a period of 5 minutes. Her GCS fell to 7. She was intubated and received 5ml/kg mannitol 20% for presumed cerebral oedema. The 8% fluid deficit was recalculated to replace over 72 hours. A non-contrast CT brain was performed following stabilisation. This showed effacement of the quadrigeminal plate, ambient and interpenduncular cisterns, as well as the cerebral sulci, with preservation of grey/white matter differentiation (Figure 1a and 1b).

Five hours following presentation. Non contrast axial CT through the  brain in e uncus and parahippocampal gyrus (A) There was also effacement of the cerebral sulci superiorly (B) All suggestive of diffuse cerebral edema.

Figure 1 Five hours following presentation. Non contrast axial CT through the brain in e uncus and parahippocampal gyrus (A) There was also effacement of the cerebral sulci superiorly (B) All suggestive of diffuse cerebral edema.

A diagnosis of cerebral oedema was made.

Intravenous insulin was commenced at 0.1u/kg/hr after one hour of intravenous fluids. Intravenous fluids were initially 0.9% NaCl. Dextrose 5% was added to fluids at 5 hours to maintain normoglycaemia and 0.9% NaCl was changed to 0.45% NaCl at 18 hours. Insulin dose was titrated to 0.05 u/kg/hr at 15 hours. Extubation was attempted at 5 hours, but was postponed due to increasing agitation. A planned repeat dose of mannitol was given at 6 hours. Morphine and midazolam was continued until 20 hours, and was weaned prior to successful extubation. Her neurological examination was normal. Her pH, glucose, corrected sodium, osmolality and electrolytes remained within acceptable limits throughout management (Figure 2).

Slow normalisation of Glucose (A); pH(B); HCO3 (C); Base Excess (D); Corrected Sodium (E); and Osmolality (F).

Figure 2 Slow normalisation of Glucose (A); pH(B); HCO3 (C); Base Excess (D); Corrected Sodium (E); and Osmolality (F).

At 45 hours, she had fully recovered clinically and was commenced on subcutaneous insulin before breakfast and intravenous insulin was discontinued at 46 hours.

At 50 hours, she became acutely less responsive. She initially localised to pain and speech consisted of inappropriate words (GCS 9). A futher dose of intravenous mannitol 20% (5ml/kg) was administered. Her GCS returned to 15 within half an hour. An MRI brain was subsequently performed (Figure 3).

Axial diffusion weighted image through the base of the brain,  demonstrates abnormal bright signal in the inferior frontal lobes and uncal  regions bilaterally, and left hippocampal body  (A) Theseabnormalities were also dark on the ADC map  (B) Confirming restricted diffusion and acute irreversible cytotoxic edema.

Figure 3 Axial diffusion weighted image through the base of the brain, demonstrates abnormal bright signal in the inferior frontal lobes and uncal regions bilaterally, and left hippocampal body (A) Theseabnormalities were also dark on the ADC map (B) Confirming restricted diffusion and acute irreversible cytotoxic edema.

This showed areas of abnormal T2 and T2 FLAIR, signal in several regions in the base of the brain, including the inferior frontal lobes posteriorly, the uncus and amygdala of the mesial temporal lobes bilaterally, both occipital lobes antermoedially and in the splenium of the corpus callosum. These areas showed restriction on diffusion-weighted imaging. The ventricles, cisterns and sulci looked patent and there was no cerebellar herniation. This distribution pattern was considered to be secondary to mass effect due to acute cerebral oedema, which had resolved by the time of the MRI. A repeat MRI brain was performed 2 weeks later showed improvement but not complete resolution of the above findings. She made a full recovery. There are no neurological sequellae at follow up three years after this event.

DISCUSSION

The annual risk of DKA in children with established type 1 diabetes is 8%, with risk factors including poor metabolic control, reduced access to medical services, pubertal females and psychiatric disorders [2]. At least two thirds of diabetes related mortality is related to DKA, with over two thirds of those being due to cerebral oedema [3]. Up to 40% of children who have had cerebral oedema have subsequent neurological sequelae [4,5]. Despite the increased morbidity and mortality associated with cerebral oedema in DKA, the aetiology is poorly understood. The majority of cases of cerebral oedema occur within 14 hours of treatment initiation [6], often after a period of clincial improvement. Some degree of increased intracranial pressure, manifested as ventricular narrowing, occurs in up to half of children with DKA [7]. but what causes a small proportion of those develop clinical cerebral oedema remains largely unknown. New diagnosis [4], increased serum urea nitrogen and reduced partial pressures of arterial carbon dioxide at presentation [6] convey an increased risk of developing cerebral oedema. Treatment with bicarbonate [6] or profound falls in serum osmolality [8] also increase the risk. Rapid rehydration [9,10] is also conisidered to increase the risk, and generally accepted management guidelines [1,11] mandate slow rehydration. Whether or not slower rehydration regimes have a protective effect is unclear and small studies suggest no difference in subclinical cerebral oedema between slow and more rapid rehydration [12]. The early onset of cerebral oedema following commencement of therapy may be a consequence of altered cerebral metabolism in DKA, followed by possible cerebral hypoperfusion and reperfusion injuries with treatment [13]. While the majority of cases occur soon after commencing therapy, recurrence following successful therapy has not previously been reported. In the case described, a 7 year-old girl with moderate DKA developed clinical and radiological cerebral oedema soon after commencing mangement in line with clincial guidelines. Despite careful appropriate normalisation of biochemical parameters, she had a second acute episode of deterioration at 50 hours. 

The aetiology of this unexpected recurrence is unknown, and further highlights our poor understanding of the pathogenesis of this serious complication. Vasogenic cerebral oedema is associated with an elevated diffusion coefficient on diffusion weighted MRI, and this is seen during typical cerebral oedema in DKA. In this patient’s second episode, there was decreased diffusion on MRI. This suggests cytotoxic oedema and may have been a response to injury or ischaemia from the first episode.

While the trigger for her clinical deterioration is unclear, this case highlights the need for ongoing close observation following clinical improvement. Close observation should continue for 72 hours, and consideration given to reimaging if there are any concerns. In this case, the restricted diffusion on the initial MRI would suggest that the abnormalities secondary to the cerebral oedema were irreversible. This emphasizes the seriousness of this complication and the need for medical vigilance to detect and treat this condition. Fortunately there appear to be no long term sequelae at three years follow-up.

REFERENCES

1. Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009; 12: 118- 33.

2. Rewers A, Chase HP, Mackenzie T, Walravens P, Roback M, Rewers M, et al. Predictors of acute complications in children with type 1 diabetes. JAMA. 2002; 15: 287- 8.

3. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. 1999; 81: 318- 23.

4. Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child. 2001; 85: 16- 22.

5. Rosenbloom AL. Intracerebral crises during treatment of diabetic ketoacidosis. Diabetes Care. 1990; 13: 22- 33.

6. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001; 344: 264- 9.

7. Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006; 7: 75-80.

8. Durward A, Ferguson LP, Taylor D, Murdoch IA, Tibby SM. The temporal relationship between glucose-corrected serum sodium and neurological status in severe diabetic ketoacidosis. Arch Dis Child. 2011; 96: 50- 7.

9. Duck SC, Wyatt DT. Factors associated with brain herniation in the treatment of diabetic ketoacidosis. J Pediatr. 1988; 113: 10-4.

10. Mahoney CP, Vlcek BW, DelAguila M. Risk factors for developing brain herniation during diabetic ketoacidosis. Pediatr Neurol. 1999; 21: 721-7.

11. Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TP, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics. 2004; 113: e133- 4.

12. Glaser NS, Wootton-Gorges SL, Buonocore MH, Tancredi DJ, Marcin JP, Caltagirone R, et al. Subclinical cerebral edema in children with diabetic ketoacidosis randomized to 2 different rehydration protocols. Pediatrics. 2013; 131: e73-80.

13. Glaser N, Yuen N, Anderson SE, Tancredi DJ, O’Donnell ME. Cerebral metabolic alterations in rats with diabetic ketoacidosis: effects of treatment with insulin and intravenous fluids and effects of bumetanide. Diabetes. 2010; 59: 702-9.

Hawkes CP, Laffan EE, Murphy NP (2013) A Case of Recurrent Cerebral Oedema in Diabetic Ketoacidosis. J Endocrinol Diabetes Obes 1(1): 1001.

Received : 27 Jun 2013
Accepted : 05 Aug 2013
Published : 07 Aug 2013
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X