UNUSUAL COMPLICATION IN

DKA
Dr. Swapna
Fellow in Paediatric Intensive care
ICH&HC
Guide: Dr. Poovazhagi
HISTORY
2/ MCh
Polyuria and polydipsia – 2 weeks
Fever-2 days
Treated as DKA and referred to ICH
D1- cerebral oedema.Intubated
D4- sensorium normal. Extubated
24 hrs later- ALOC and seizures
Developed shock ,AKI and anaemia and
thrombocytopenia
D6- reintubated
EXAMINATION
Febrile,102°F, pale
GCS-E₂VTM₄
B/L PERL
Tone normal, Reflexes 2+, Power- 3/5, plantar- B/L
flexor
No meningeal signs
Child on mechanical ventilation
INVESTIGATIONS
10/12 12/12 14/12 16/12 17/12 18/12 20/12 22/12
TC 19700 13400 10600 11800 12500 13600 11300 6400
DC 54/41 40/52 53/40 38/50 55/45 36/55 74/22 47/39
/4 7/ /7 /11 /3 /13
Hb 8 6.3 7.8 6.2 7.2 6.9 6.3 7.0
PCV 30 22 24 21.5 24.7 23.4 21.6 24.6
PLT 4.5 L 95000 56000 52000 59000 85000 1.17 1.79
lakhs lakhs
RBC 5.8 4.1 4.4 3.4 3.3 3.3 3.9
MCV 52 56 55 57.5 63.9 62.3
MCH 31 14 17 16.6 18.6 17.7
MCHC 26 28 32 28.8 29.2 28.5
RDW 21.4 21.5 32.9 32.2 37 36.5
INVESTIGATIONS
10/12 11/12 13/12 14/12 16/12 18/12 19/12 20/12
Urea( 22 80 28 65 20 16 21 21
mg/dl)
Creat 1.0 1.2 0.9 1.0 0.4 0.3 0.2 0.4
(mg/dl
)
Na 129 160 163 155 153 154 148 142
K 4.0 2.7 4.0 4.4 2.9 3.8 3.0 4.1
Ca 7.4 7.7 8.1 8.2
Mg 1.2 1.6 1.8
SGOT 269 135
SGPT 574 416
LDH 1647 1133 939
ISSUES
 New onset DKA with cerebral oedema
 Recovered -normal sensorium

 Decline of sensorium subsequently/ seizures

 Worsening anaemia

 New onset thrombocytopenia

 Transient elevation of renal parameters

 Evidence of hemolysis

 Persisting fever

 No bleeding
PROBABILITIES
 ALOC/renal
failure/anaemia/thrombocytopenia/fever
 Cerebral edema
 Sepsis/DIVC
 Renal failure due to ATN
 HUS
 TTP
 Reticulocyte count- initially 1% , later 6%
RPI-1.5
 PS- schistocytes present. Suggestive of MAHA

 DCT- negative

 PT/aPTT- normal

 Fibrinogen- normal

 NEC- no growth

 CRP- negative

 Urine C/S- Candida parapsilosis

 MRI brain- cortical hyperintensities in bilateral
frontal and parietal regions- post ictal changes
Repeat MRI- diffuse cerebral atrophy
 CSF analysis- normal, culture- no growth

 Anti factor H- negative, C3- 231 mg/dl(80-200)

 Autoimmune encephalitis panel- negative

 Anti GAD 45 -881 U/ml(>5 IU- positive)

 EEG- diffuse slowing

COURSE IN PICU
Nephrology opinion obtained on day 1 of admission-
Planned for plasmapheresis. ↓ LDH,↑platelets
and hence FFP transfusion given for 3 days
D4- sensorium regained and extubated
D5- Developed choreoathetotic movements and
orofacial dyskinesias with visual impairment-
suspected autoimmune encephalitis and treated
with ivIg 2g/kg
FOLLOW UP
Motor development-
6 weeks later- achieved sitting without support
8 weeks later-walking independently
Language- babbling
Turns to sound
Not fixing or following light
Ophthal- fundus normal
Hearing assessment- normal
TMA
 TAMOF- Thrombocytopenia associated multi
organ failure
 Sick child with microangiopathy with
thrombocytopenia is a challenge in ICU
 Needs immediate work up for HUS/TTP

 Clinical differentiation in the absence of

laboratory support is difficult

Nquyen TC, Carcillo JA. Bench-to-bedside review: Thrombocytopenia-associated

multiple organ failure —a newly appreciated syndrome in the critically ill. Crit Care.
2006;10:235.
Joly, B. S., Zheng, X. L., & Veyradier, A. (2018). Understanding thrombotic
microangiopathies in children. Intensive care medicine, 44(9), 1536–1538.
CLINICAL SPECTRUM OF TMA
DIC HUS TTP SECONDARY
TMA
Thrombocytopenia Thrombocyto Fever
penia
Prolonged PT/a Renal Thrombocytope Thrombocytope
PTT dysfunction nia nia
Increased d dimer MAHA ↑LDH Increased LDH
↓Antithrombin, Schistocytes Schistocytes <5
protein C >5% %
↓ Factor V, X, Renal Multi organ
fibrinogen dysfunction failure
Neurologic Normal or
dysfunction elevated
fibrinogen
 Treatment- plasma exchange. Initiated within 24
hrs of diagnosis and continued till normalisation
of platelet counts(>1.5 lakhs) and serum LDH for
two consecutive days
 Plasma infusion

Kumar, R., McSharry, B., Bradbeer, P., Wiltshire, E., & Jefferies, C. (2016).
Thrombocytopenia-associated multiorgan failure occurring in an infant at the
onset of type 1 diabetes successfully treated with fresh frozen plasma. Clinical
case reports, 4(7), 671–674.
REFERENCES
 Khan MR, Maheshwari PK, Haque A. Thrombotic
microangiopathic syndrome: A novel complication of
diabetic ketoacidosis. Indian Pediatr 2013; 50:697-9
 Patra KP, Scott LK. Diabetic ketoacidosis preceding
thrombocytopenia associated multiple organ failure in a
child. JOP 2011; 12:40-3.  
 
 Merrick VM, Vaidya M. Diabetic ketoacidosis (dka)
preceding thrombocytopenia associated with acute renal
failure and pancreatic enzyme elevation. Pediatr Crit Care
Med 2014; 15 Suppl 1:P16
THANK YOU