Aims/Introduction Diabetic Ketoacidosis (DKA) is a potentially fatal complication of Type 1 Diabetes Mellitus (T1DM). Cerebral complications affect 0.3%–1% of patients with DKA and cerebral infarction or haemorrhage is thought to account for 10% of these. There is little published evidence on cerebral infarction in children with DKA. Here we present a rare case of a 4 year old girl who presented with a new diagnosis of T1DM in severe DKA with subsequent development of cerebral infarction.

Method/Description of case A 4 year old girl presented with decreased appetite, polyuria, polydipsia, drowsiness and weight loss to our tertiary paediatric hospital. On arrival her GCS was 10–12, blood gas showed a pH 6.82, base deficit 31, blood glucose 20 mmol/L and ketones 4.6 mmol/L. Diagnosis of severe DKA was made and managed according to ISPAD guidelines. Total fluid boluses of 20 ml/kg were given due to prolonged capillary refill. Following initial resuscitation IV mannitol was administered due to concerns regarding possible cerebral oedema with support from PICU. The patient showed good clinical and biochemical improvement over the next 48 hours and was planned for conversion onto subcutaneous insulin. However subsequently there was a gradual deterioration of renal function. On day 3 acute kidney injury stage 3 was diagnosed and she began to develop right arm weakness through the morning, suddenly becoming floppy and unresponsive in the afternoon. Urgent MRI head showed a left peripheral cerebral artery occlusion and ischaemia in the left posterior lobe. Management involving paediatric nephrologist and neurologist was conservative and with intensive rehabilitation she showed good improvement. Following a 3 week admission she was able to walk unaided and discharged home on insulin pump therapy with follow up with Neurology, Renal and Diabetes teams.

Result Acute cerebral infarction following an episode of severe DKA, improved with supportive management.

Conclusion This case highlights the importance of awareness of the rare risk of cerebral infarction in severe DKA. Patients recovering from DKA should be closely monitored neurologically and if any deterioration occur an urgent brain scan should be carried out with early involvement of a tertiary paediatric neurological team.