Rhabdomyolysis in Pediatric Patients With Diabetic Ketoacidosis or Hyperglycemic Hyperosmolar State: A Case Series

Recognizing Complications in Youth With Diabetes Admitted With Diabetic Ketoacidosis Versus Hyperglycemic Hyperosmolar State

INTRODUCTION

We compare in-hospital complications in youth with isolated diabetic ketoacidosis (DKA) to youth with hyperosmolarity.

METHOD

We reviewed medical records of youth (1-20 years) admitted over two years with DKA, hyperglycemic hyperosmolar state (HHS), and hyperosmolar DKA. We evaluated outcomes, including hospital length of stay, altered mental status (AMS), and acute kidney injury (AKI).

RESULTS

Of 369 admissions, 334 had isolated DKA, 32 had hyperosmolar DKA, and three had isolated HHS. Hyperosmolar youth had longer length of stay, larger initial fluid boluses, more frequent pediatric intensive care unit admissions, and increased risk of AKI and AMS. The odds of AKI were positively associated with serum osmolality and negatively associated with new-onset diabetes mellitus (DM) compared with established DM.

CONCLUSIONS

In youth with DM, hyperosmolarity increases acute complications compared with isolated DKA. Larger-scale studies are needed to identify ways to prevent acute complications in youth experiencing hyperglycemic emergencies.

A case report of rhabdomyolysis and osteofascial compartment syndrome in a patient with hypothyroidism and diabetes

BACKGROUND

Hypothyroidism is frequent and has various forms of muscle involvement. We report the diagnosis and treatment of a case of rhabdomyolysis, bilateral osteofascial compartment syndrome (OCS) of the lower extremities, and peroneal nerve injury causing bilateral foot drop in a diabetic patient with hypothyroidism.

CASE PRESENTATION

A 66-year-old man with diabetes for 22 years was admitted because of drowsiness, tiredness, facial swelling, and limb twitching for 2 months, and red and swollen lower limb skin for 3 days. Serum creatinine kinase (CK), CK-MB, myoglobin (Mb), blood glucose, and HbA1c were elevated. TSH, thyroid peroxidase antibodies, and antithyroglobulin antibodies were elevated. FT3 and FT4 were low. Urine was dark brown. He was diagnosed with hypothyroidism, rhabdomyolysis, and OCS. CK, CK-MB, and Mb returned to normal after treatment with thyroid hormone, insulin, albumin infusion, ceftriaxone, ulinastatin, and hemofiltration, and the redness and swelling of the lower limbs were relieved, but the patient developed dropping feet. The patient recovered well but had to undergo rehabilitation.

CONCLUSION

Hypothyroidism may induce rhabdomyolysis, OCS, and other complications. This case reminds us of the importance of screening for hypothyroidism and strengthens the clinicians' understanding of the disease.

Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus

Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.

Rhabdomyolysis; is it an overlooked DKA complication

BACKGROUND

Rhabdomyolysis is considered by some studies as a rare complication of a common disorder of diabetic ketoacidosis, while others consider it as not so uncommon. The mechanism is still not clear but can be attributed to a number of factors like acidosis, hyperglycemia and electrolyte disturbances especially hypophosphatemia and hypokalaemia. Missing it may lead to more serious complications and may prolong and/or complicate full recovery of diabetic ketoacidosis.

AIM

The aim of this study was to measure the incidence of rhabdomyolysis among patients presented with diabetic ketoacidosis in the emergency department of Baghdad Teaching hospital, its relation to the severity of diabetic ketoacidosis and the associated electrolytes disturbances.

PATIENTS AND METHODS

This is a cross sectional study carried out in the emergency department of Baghdad teaching hospital/Iraq; where 43 patients with type1 diabetes presenting with diabetic ketoacidosis were included. Diabetic ketoacidosis was classified into mild, moderate and severe, and the incidence of rhabdomyolysis was calculated accordingly. Full blood investigations, urinary ketones and arterial blood gasses were done.

RESULTS

Rhabdomyolysis was found in 3 (6.98%) patients with more severe acidosis and urinary ketones in the setting of moderate and severe diabetic ketoacidosis. Statistically significant finding was observed with the duration of diabetes, higher serum creatinine, higher serum potassium, higher serum chloride, severe acidosis and urinary ketones.

CONCLUSIONS

Rhabdomyolysis incidence in this study was 6.98% of patients with more severe acidosis, urinary ketones in the setting of moderate to severe diabetic ketoacidosis and with longer duration of diabetes.