MON-128 Pneumomediastinum in Diabetic Ketoacidosis

Background: Pneumomediastinum (PM) is a well recognized but uncommon complication in DKA. Recognizing PM as a mostly benign and self resolving complication of DKA will prevent unnecessary investigations. Clinical case: A 27 year male with history of type 2 diabetes and DKA in the past presented to the emergency with decreased appetite, cramping abdominal pain, vomiting, central chest pain and shortness of breath for three days. He had been non-compliant with his insulin and had not used any for the past week. He was obese with BMI of 31 kg/m(2), afebrile, tachycardic HR 121/min, tachypnic RR 23/min, blood pressure was 173/91, spO2 98%, oral mucosa was dry and abdomen was mildly tender.He was found to be in DKA with pH of 6.9, anion gap 23(6-12), bicarbonate 7 mEq/L(22-28), beta-hydroxy-butyrate 100 mmol/L(0.3-0.5), sodium 137 mEq/L(136-145), potassium 6 mEq/L(3.5-5.0), chloride 107 mEq/L (98-106), BUN 17 mmol/L(8-20), creatinine 1.79 mg/dL(0.7-1.3), lipase 153 U/L(<160). DKA was treated with IV fluids, bicarbonate and insulin. Chest xray showed pneumomediastinum which was confirmed with the CT chest. Gastrograffin esophagogram was also done which ruled out esophageal perforation. Serial chest xrays were done which showed resolution of PM in three days.PM complicating DKA is rare, and has been reported mostly in young males taking insulin. Pneumothorax, pneumopericardium, and epidural pneumatosis are other pneumo-complications reported in DKA patients. Vomiting and Kussmaul’s breathing associated with severe DKA can cause alveolar overdistension and barotrauma with subsequent air leakage into the mediastinum. Hamman’s sign is a frequent physical exam finding. A standard chest radiograph (2-view xrays to find small PM) or CT can establish the diagnosis of PM. PM in DKA has a relatively benign course, and treatment is mainly supportive. In situations with high suspicion of esophageal rupture, contrast esophagogram needs to be done, however such incidence is very rare. Conclusion: PM complicating DKA is a rare finding with benign course and excellant prognosis. Patient presents with chest pain or breathlessness, Kussmaul's respirations and profound acidosis. Chest radiography should be ordered to confirm the diagnosis. Resolution follows treatment of DKA. Esophageal perforation is very rare, which can be ruled out with contrast esophagogram in high clinical suspision. Recognizing severe DKA can cause PM will prevent unnecessary investigations. Reference: Makdsi F, Kolade VO. Diabetic ketoacidosis with pneumomediastinum: a case report. Cases J. 2009;2:8095. Steenkamp D, Patel V, Minkin R. A Case of Pneumomediastinum: A Rare Complication of Diabetic Ketoacidosis. Clinical Diabetes Apr 2011, 29 (2) 76-77.