1 - Unidade de Cuidados Intensivos Pediátricos, Área da Pediatria, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
2 - Serviço de Cirurgia Pediátrica, Área da Pediatria, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
3 - Unidade de Neurologia Pediátrica, Área da Pediatria, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
4 - Unidade de Endocrinologia Pediátrica, Área da Pediatria, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
5 - Unidade de Infeciologia, Área da Pediatria, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
- ESPNIC X 2021, reunião internacional (poster)
Resumo:
Background and aims: Diabetic ketoacidosis (DKA) is a serious condition associated with several complications. Prompt diagnosis and correct management are essential to enhance the prognosis. In this case we were confronted with major setbacks, demanding a nonlinear multidisciplinary approach.
Methods: Results: A fourteen-year-old girl admitted with new-onset DKA in a Pediatric Intensive Care Unit, presenting severe ketoacidosis (pH 6,8; bicarbonate 3,8mmol/L, glycemia 669mg/dL, cetonemia 4,5mmol/L), Kussmaul breathing and obnubilation. Initial approach with IV fluids and insulin perfusion according to the national protocol revealed insufficient to correct the ketoacidosis. An infected pilonidal sinus was diagnosed and treated with triple antibiotic scheme and debridement. SARS-CoV-2 PCR was negative, but IgG was positive (546U/mL). She aggravated with refractory shock, persistent acidosis (pH<7, bicarbonate <12mmol/L), acute kidney injury and depressed level of consciousness leading to invasive ventilation and aminergic support. Further surgical approach revealed a deeper lesion. Neurological deterioration was evidenced by an electroencephalogram with signs of diffuse encephalopathy and a cranial MRI showed vasogenic edema compatible with posterior reversible encephalopathy syndrome (PRES). After clinical stability and transition to subcutaneous insulin she had two relapses of ketoacidosis needing to reinitiate insulin perfusion. Thereafter she showed a favorable clinical and neurological outcome.
Conclusions: In this case the depressed level of consciousness was present since the beginning making the management between fluid restriction attending to the risk of cerebral edema and fluid resuscitation for the refractory shock an important therapeutic challenge. Probably both DKA and sepsis contributed to the development of PRES. We question if MIS-C played a role in this case.
Palavras Chave: diabetic ketoacidosis, pilonidal sinus, PRES, sepsis.