Myocardial Dysfunction Associated with Diabetic Ketoacidosis and Influenza Infection

Introduction: The incidence of myocardial dysfunction in DKA is not common. DKA is the most common reason for pediatric intensive care unit. Complications can be mainly due to fast correction of the hyperglycemia, cerebral edema, electrolyte disturbances and hypoglycemia.Acute respiratory failure might occur and can be due to various factors, including myocardial dysfunction.

Case report: A 4-year-old male was admitted to the emergency room with non-compensated shock, four days before he was presented to our hospital he had history of viral gastroenteritis and weakness. Initial examination of the child showed signs of non-compensated shock with severe hyperglycemia accompanied with metabolic acidosis. boluses of normal saline and vasopressors was started and the patient became hemodynamically stable.

On the primary survey the quick Point of Care Ultrasound (POCUS) was normal with good cardiac contractility without signs of pericardial effusion, the IVC was not plethoric and troponin was negative, head CT was done and it was normal without any signs of cerebral edema. The child was transferred to the ICU with continues treatment of vasopressors and initial drip of insulin, a good response to the treatment was detected. After 12 hours the child had symptoms of severe tachycardia and low blood pressure. Laboratory findings showed high levels of troponin, respiratory panel return positive to Influenza A. ECG showed ST elevation, on cardiac Echo myocardial depression with mitral regurgitation and EF 30% was detected. The child was placed on ECMO for further treatment.

Conclusion: Cardiogenic dysfunction with findings of DKA can be the initial manifestation of acute myocarditis specifically after acute viral illness.