Concurrent DKA, Pancreatitis, and Cardiogenic Stroke in an Adolescent: True, True, and…Related?

Introduction: Diabetic ketoacidosis (DKA) is a leading cause of diabetes-related morbidity and mortality in children. Neurologic complications, mainly cerebral edema, are the most feared sequelae of DKA. Although rarer, arterial ischemic stroke (AIS) in DKA may be under-diagnosed due to overlapping clinical features with other DKA-related neurologic findings. Risk factors for developing AIS in DKA include dehydration, acidosis, cerebral hypoperfusion, and a prothrombotic state. In addition, ruling out cardiac causes is a critical step in the evaluation of AIS in DKA.


Description: A previously healthy 10-year-old girl with one week of malaise and one day of abdominal pain was admitted to the intensive care unit for encephalopathy associated with severe DKA (glucose 709 mg/dL, pH 6.9, HCO3 < 5 mEq/L). Abdominal pain with tenderness on exam and elevated lipase (3,805 U/L) led to diagnosis of acute pancreatitis, though abdominal US was unremarkable.
On day 2, she developed left upper and lower extremity weakness, prompting a head CT/A that showed acute infarcts in the right thalamus and left inferomedial cerebellum. Echocardiogram revealed a large, mobile, pedunculated mass on the mitral valve, concerning for papillary fibroelastoma vs. thrombus. Aspirin therapy was initiated, and later transitioned to a heparin infusion.
Cardiac MRI supported findings of papillary fibroelastoma, and a follow-up brain MRI showed additional infarcts in the right hippocampus, left inferior colliculus, and cerebellar vermis. Surgical excision was recommended but deferred for 14 days due to the risk of hemorrhagic conversion with cardiopulmonary bypass. Surgical pathology reported fibrin thrombi with valvular strands, consistent with a thromboembolic source not a fibroelastoma. Postoperatively, she was transitioned to aspirin therapy, and ambulatory echocardiogram confirmed resolution of the mass.


Discussion: AIS is a rare but serious complication of pediatric DKA. This is one of the first reports of cardioembolic stroke associated with DKA and its management challenges. This case underscores the need for heightened vigilance in identifying potential markers of DKA severity, evaluating the multifactorial mechanisms of stroke, and further exploring the role of anticoagulation in similar presentations.