New-Onset Pediatric Diabetes Complicated By Diabetic Ketoacidosis and Invasive Rhinocerebral Mucormycosis With Internal Carotid Artery Occlusion

• Published in: The Journal of emergency medicine 2022-01, Vol.62 (1), p.95-100
• Main Authors: Mahan, Keenan M., Molina, Melanie F., Coffey, El Centro C., Manchanda, Emily C. Cleveland
• Format: Article
• Language: English
• Subjects: Adolescent; Carotid Artery Diseases - complications; carotid artery occlusion; Carotid Artery, Internal; cerebral edema; Child; Diabetes Mellitus; diabetic ketoacidosis; Diabetic Ketoacidosis - diagnosis; Humans; Hyperglycemic Hyperosmolar Nonketotic Coma; Male; mucormycosis; Mucormycosis - complications; Mucormycosis - diagnosis; neuroimaging; otorhinolaryngology; pediatrics
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2021.07.024

Diabetic ketoacidosis (DKA) has increased in prevalence in the emergency department (ED) in recent years. The complications of DKA are life threatening and necessitate rapid identification and management. Pediatric complications include cerebral edema, venous thrombosis, acute kidney injury, and severe infections including necrotizing fasciitis and mucormycosis. Rhinocerebral mucormycosis carries a high mortality rate and requires early treatment with antifungals and surgical debridement. A 16-year-old boy with no significant past medical history presented to the ED with new-onset DKA complicated by hypothermia, hyperosmolar hyperglycemic state, cerebral edema, and multifactorial shock. During a complicated pediatric intensive care unit admission, he was found to have fatal invasive rhinocerebral mucormycosis, causing internal carotid artery occlusion with evidence of both direct and hematogenous spread into his brain. Early identification of shock and appropriate management with intravenous fluids, vasopressors, and reversal of the underlying process is key in hypotensive children. In pediatric DKA, the emergency physician must consider cerebral edema, appropriate fluid resuscitation, and identify the likely precipitants leading to the onset of DKA. Thorough workup for potential precipitants should be initiated in the ED, searching for etiologies including infection, intoxication, insulin deficiency, inflammation, and ischemia. We must remember that pediatric patients, especially those with new DKA, are susceptible to life-threatening infection, including mucormycosis. Mucormycosis is a rare diagnosis, and management includes antifungal therapies and involvement of otorhinolaryngology.