Central Pontine Myelinolysis in Pediatric Diabetic Ketoacidosis

Abstract

Central pontine myelinolysis (CPM) is rarely reported in pediatric patients with diabetic ketoacidosis (DKA). We report this case of a 16-year-old female with new onset diabetes presenting with DKA, who received aggressive fluid resuscitation and sodium bicarbonate in the emergency department. Later she developed altered mental status concerning for cerebral edema and received hyperosmolar therapy with only transient improvement. Soon she became apneic requiring emergent endotracheal intubation. MRI brain showed cerebral edema, CPM, and subdural hemorrhage. She was extubated on day seven and exhibited mild dysmetria, ataxia, unilateral weakness, and neglect. Upon discharge she was able to ambulate with a walker and speak and eat without difficulty. Although less common than cerebral edema, CPM should be considered in DKA patients with acute neurologic deterioration. Fluid and bicarbonate therapy should be individualized, but larger studies would help guide the management. Although poor outcomes are reported in CPM, favorable outcomes are possible.

Figure 1

T2-FLAIR Axial image showing diffuse pontine edema.

Figure 2

T2-FLAIR Sagittal image showing diffuse pontine edema and cerebral edema.

Figure 3

Restricted diffusion in pons with relative sparing of corticospinal tract.

Figure 4

FSPGR sequence, coronal image of brain showing right parietal subdural hemorrhage.