Takotsubo cardiomyopathy and cardiac arrest in a 9-year-old girl with new-onset diabetes presenting with diabetic ketoacidosis: the chicken or the egg?

Sanja Panic ZaricVladislav VukomanovićRade VukovicTatjana MilenkovićSladjana TodorovicKatarina MitrovicDimitrije CvetkovicStasa Krasic^*

• The Institute for Health Protection of Mother and Child Serbia, Belgrade, Serbia

Background: Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes mellitus type 1 (T1DM). There is no published data about the incidence of cardiac arrest in pediatric DKA. Here we present a rare case of a previously healthy 9-year-old girl with new T1DM presenting with severe DKA and influenza infection who developed cardiac arrest, ventricular tachycardia (VT) and stress cardiomyopathy during the initial hours of DKA treatment without any underlying electrolyte disorder, heart disease or hypoglycemia. Case report: A 9-year-old febrile girl was admitted to our pediatric intensive care unit (PICU) for treatment of severe DKA (pH 6.72) with normal electrolyte status. The treatment of severe DKA was promptly started, with the addition of mannitol due to computed tomography signs of mild initial cerebral swelling. In the seventh hour of DKA treatment, bradycardia developed and, within a minute, progressed to asystolic cardiac arrest with a resultant sudden drop in oxygen saturation and arterial pressure. Immediate measures of cardiopulmonary-cerebral resuscitation were started, and adrenaline and atropine were administered, which resulted in a change from asystole to polymorphic ventricular tachycardia. Two direct current cardioversions were performed, restoring the patient's sinus rhythm and stabilization. Blood gas analyses showed persistent hyperglycemia and severe metabolic acidosis (pH 6.81), without electrolyte imbalances, and a further increase in lactate levels. The girl was intubated, and mechanical ventilation was initiated. Echocardiography detected moderately impaired left ventricular systolic function, hypo-and dyskinesia of the interventricular septum. Bicarbonates and inotropic stimulation were administered. The further clinical course was uneventful, with gradual improvement, resolution of ketoacidosis, and restoration of cardiac function. A PCR test confirmed an AH3+ influenza virus infection. She was discharged after 14 days of treatment with insulin and an ACE inhibitor, with normal echocardiography findings. Conclusion: This case highlights that potentially fatal stress cardiomyopathy and cardiac arrest can unexpectedly occur during the treatment of pediatric severe DKA, even without electrolyte disturbances, brain edema or any history of prior heart disease. Given these risks, we conclude that all pediatric patients with severe DKA should be treated in the PICU with continuous ECG monitoring.