DIABETIC KETOACIDOSIS WITH EXTREME ACIDEMIA IN A PRESCHOOL CHILD WITH TYPE 1 DIABETES MELLITUS: CASE REPORT AND CHALLENGES IN METABOLIC MANAGEMENT

Abstract

Objective: To report a rare case of severe diabetic ketoacidosis (DKA) with extreme acidemia in a preschool child with type 1 diabetes mellitus (T1DM), highlighting metabolic, electrolyte, and management challenges. Case description: A 4-year-11-month-old boy with T1DM diagnosed at 12 months of age and a history of irregular follow-up and multiple previous admissions for metabolic decompensation was admitted with drowsiness, abdominal pain, vomiting, and tachypnea. Initial venous blood gas analysis revealed a pH of 6.74 and bicarbonate of 1.7 mEq/L, associated with blood glucose of 800 mg/dL and positive ketonuria (+++), consistent with severe DKA and extreme acidemia. Management included isotonic fluid resuscitation as the initial therapeutic priority, continuous intravenous insulin infusion (0.05–0.1 IU/kg/h), intensive electrolyte replacement, and sodium bicarbonate administration at admission due to the markedly low pH (<6.9). During the first 48 hours, the patient presented persistent metabolic instability, significant glycemic fluctuations, and marked hypokalemia, without clinical or radiological evidence of cerebral edema. Progressive metabolic recovery occurred, with normalization of acid–base status (final pH 7.44; bicarbonate 27.8 mEq/L), followed by transition to subcutaneous insulin. Comments: Extreme acidemia (pH <6.8) in pediatric DKA is uncommon and associated with increased risk of neurological and cardiovascular complications. This case underscores the complexity of managing severe DKA, particularly in the context of poor therapeutic adherence, and highlights the importance of adequate intravenous hydration and multidisciplinary strategies to prevent recurrence.