(875) Spontaneous Pneumorrhachis in a Child With Severe Diabetic Ketoacidosis

Introduction: Pneumorrhachis is a rare radiologic finding where air is seen in the spinal canal. Its etiology varies, trauma being the most common cause. We report the case and management of a child with severe diabetic ketoacidosis (DKA) who presented with spontaneous pneumorrhachis and extensive pneumomediastinum and pneumopericardium.

Description: The patient was a 10-year old female transferred from an outside hospital with severe DKA. She presented with tachycardia, somnolence and severe Kussmaul respirations but no history of vomiting or coughing. Her initial laboratory exam revealed unreadable elevated blood glucose by glucometer, pH 6.85, total CO2 5 mEq/L , and anion gap of 38 mmol/L. Initial chest X-ray demonstrated extensive pneumomediastinum and pneumopericardium. Neck, chest and spinal computed tomography revealed massive pneumomediastinum with air tracking into the soft tissues of the retropharyngeal, anterior paravertebral and bilateral carotid spaces and air in the epidural space of the spinal canal (pneumorrhachis) extending from C2 to L1. No pneumothorax was identified. An echocardiogram (limited acoustic windows) demonstrated a small posterior pericardial effusion and good function. Management of her DKA was done per standard protocol, her air leak was managed with comfort measures. She remained in the PICU for close cardiorespiratory monitoring. A follow up spine MRI on hospital day (HD) # 6 showed resolution of the pneumorrhachis; the pneumopericardium and pneumomediastinum resolved over several days. Esophagogram was not done as suspicion for esophageal injury was very low and she tolerated oral intake without complications. She was discharged home in stable condition on HD# 9.

Discussion: Spontaneous pneumomediastinum without history of forceful vomiting is an infrequent complication reported in patients with DKA. The increased intrathoracic pressure triggered by Kussmaul breathing leads to alveolar overdistension and rupture, with air leaking into the mediastinum. Pneumorrhachis, a very rare finding, is caused by dissection of the air through the intervertebral foramen reaching the spinal canal. This case underscores the importance of considering atypical complications of severe diabetic ketoacidosis in pediatric patients, early recognition, and its conservative management.