Ann Pediatr Endocrinol Metab.  2018 Jun;23(2):103-106. 10.6065/apem.2018.23.2.103.

Respiratory failure in a diabetic ketoacidosis patient with severe hypophosphatemia

• Choi HS
• Kwon A
• Chae HW
• Suh J
• Kim DH
• Kim HS

• KMID: 2417768
• DOI: http://doi.org/10.6065/apem.2018.23.2.103

Abstract

Phosphate is essential in regulating human metabolic processes, and severe hypophosphatemia can induce neurologic and hematological complications and result in respiratory failure and cardiac dysfunction. Therefore, correction of severe hypophosphatemia can be pivotal in the management of diabetic ketoacidosis (DKA). We report the case of a 14-year-old female who was diagnosed with type 1 diabetes and referred to our institute for treatment of DKA. Although the patient received fluid and continuous insulin administration according to the current DKA treatment protocol, generalized tonic seizures and cardiac arrest developed. After cardiopulmonary resuscitation, the patient recovered and was stable. Within 16 hours after DKA treatment, the patient developed respiratory failure with severe hypophosphatemia that required mechanical ventilation. Concurrent neurologic evaluation revealed no specific abnormalities. The patient recovered without any complications after correcting the hypophosphatemia. We suggest vigilant monitoring of the phosphate level in DKA patients and active replacement when required.

Keyword

Diabetic ketoacidosis; Hypophosphatemia; Respiratory failure

MeSH Terms

Adolescent
Cardiopulmonary Resuscitation
Clinical Protocols
Diabetic Ketoacidosis*
Female
Heart Arrest
Humans
Hypophosphatemia*
Insulin
Metabolism
Respiration, Artificial
Respiratory Insufficiency*
Seizures
Insulin

Reference

References

1. Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009; 10 Suppl 12:118–33.

2. Wilson HK, Keuer SP, Lea AS, Boyd AE 3rd, Eknoyan G. Phosphate therapy in diabetic ketoacidosis. Arch Intern Med. 1982; 142:517–20.

3. Fisher JN, Kitabchi AE. A randomized study of phosphate therapy in the treatment of diabetic ketoacidosis. J Clin Endocrinol Metab. 1983; 57:177–80.

4. Gaasbeek A, Meinders AE. Hypophosphatemia: an update on its etiology and treatment. Am J Med. 2005; 118:1094–101.

5. Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014; 15 Suppl 20:154–79.

6. Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH. Respiratory failure in diabetic ketoacidosis. World J Diabetes. 2015; 6:1009–23.

7. Ditzel J, Lervang HH. Disturbance of inorganic phosphate metabolism in diabetes mellitus: clinical manifestations of phosphorus-depletion syndrome during recovery from diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2010; 3:319–24.

8. Gibby OM, Veale KE, Hayes TM, Jones JG, Wardrop CA. Oxygen availability from the blood and the effect of phosphate replacement on erythrocyte 2,3-diphosphoglycerate and haemoglobin-oxygen affinity in diabetic ketoacidosis. Diabetologia. 1978; 15:381–5.

9. Liu PY, Jeng CY. Severe hypophosphatemia in a patient with diabetic ketoacidosis and acute respiratory failure. J Chin Med Assoc. 2004; 67:355–9.

10. Spicek-Macan J, Hodoba N, Kolarić N, Nikolić I, Majerić-Kogler V, Popović-Grle S. Immeasurable levels of serum phosphate: an unidentified cause of respiratory failure in a diabetic patient. Coll Antropol. 2010; 34:1457–60.

11. Hasselstrøm L, Wimberley PD, Nielsen VG. Hypophosphatemia and acute respiratory failure in a diabetic patient. Intensive Care Med. 1986; 12:429–31.

12. Osuka A, Matsuoka T, Idoguchi K. Is this the worst outcome of metabolic syndrome? Hypophosphatemia and resulting cardiac arrest during the treatment of diabetic ketoacidosis with hypertriglyceridemia. Intern Med. 2009; 48:1391–5.

13. de Oliveira Iglesias SB, Pons Leite H, de Carvalho WB. Hypophosphatemia-induced seizure in a child with diabetic ketoacidosis. Pediatr Emerg Care. 2009; 25:859–61.

14. Mégarbane B, Guerrier G, Blancher A, Meas T, Guillausseau PJ, Baud FJ. A possible hypophosphatemia-induced, life-threatening encephalopathy in diabetic ketoacidosis: a case report. Am J Med Sci. 2007; 333:384–6.

15. Shah SK, Shah L, Bhattarai S, Giri M. Rhabdomyolysis Due to severe hypophosphatemia in diabetic ketoacidosis. JNMA J Nepal Med Assoc. 2015; 53:137–40.

16. Svoren BM, Jospe N. Type 1 diabetes mellitus (immune mediated). In : Kliegman RM, Stanton B, St. Geme J, Schor N, Behrman RE, editors. Nelson textbook of pediatrics. 20th ed. Philadelphia: Elsevier Saunders;2016. p. 2763–83.