P0652 - Myopericarditis in an adolescent with diabetic ketoacidosis

Introduction:

Myopericarditis is an inflammation of the pericardial sac and adjacent myocardium with numerous etiologies. In adults, the metabolic disturbances seen in diabetic ketoacidosis (DKA) have been associated with myopericarditis in the absence of other causes. This association has not been widely reported in the pediatric literature. Here, we describe an interesting case of clinical myopericarditis in an adolescent boy admitted for acute management of DKA.

Case report:

A 14-year old male was admitted to the pediatric intensive care unit for severe DKA secondary to medication non-compliance. On admission, he had a large anion gap metabolic acidosis which was corrected over two days with fluid resuscitation and an intravenous insulin infusion. He was incidentally noted to have ST changes on bedside telemetry despite being asymptomatic. A 12-lead electrocardiogram (ECG) showed new onset diffuse ST elevation and PR depression suggestive of acute pericarditis. His troponin I level was significantly elevated at 6.47 ng/mL (<0.04 ng/mL normal). An echocardiogram demonstrated an inferior pericardial effusion. Cardiac anatomy and function were otherwise normal. He was treated with ibuprofen three times daily for two weeks and remained asymptomatic. His follow-up ECG showed resolution of pericarditis changes and repeat echocardiogram showed resolution of the pericardial effusion.

Discussion:

Diabetic ketoacidosis causes metabolic disturbances affecting multiple organ systems including the heart. Specifically, it has been associated with myocardial necrosis which can cause transient wall motion abnormalities, depressed ventricular function, and ventricular arrhythmias. Myocardial damage is reflected by an increase in plasma troponin level. Concomitant pericardial inflammation termed myopericarditis can occur and produces characteristic electrocardiographic changes. The phenomenon of myopericarditis associated with DKA has been previously described in adults. In this population, elevated cardiac troponin I levels have been shown to strongly correlate with major adverse cardiovascular events. This association has not been well recognized in the pediatric literature and could identify a subset of pediatrics patients at an increased risk for poor long-term outcomes and/or cardiac sequelae. The risk of recurrence and need for treatment of asymptomatic myopericarditis in children is unclear and represents an area with potential for research.

Conclusion:

This case of clinical myopericarditis in an adolescent male highlights a pediatric presentation of a known adult complication of DKA. This association has not been described in the pediatric literature and is likely under-recognized and undertreated. The risk of late cardiac sequelae warrants further investigation.