RESUMEN
OBJECTIVES: Cerebral edema (CE) remains one of the most feared complications of diabetic ketoacidosis (DKA) with severe morbidity and mortality. The use of computerized tomography (CT) scan in the setting of suspected cerebral edema in DKA has been minimally studied. The objective of our study was to evaluate the utility of CT scans in children with suspected cerebral edema, and secondarily to analyze the various patient characteristics of those with and without cerebral edema. METHODS: We performed a retrospective chart review of all the children with DKA secondary to T1DM admitted to our tertiary PICU in order to obtain demographic data, laboratory results, and their treatment course. Differences between the groups of suspected CE and no suspected CE were compared using linear and logistic regression for continuous and binary variables respectively. RESULTS: We identified 251 patients with DKA, 12 of which had suspected CE; 67% (8/12) of those patients received head CT and 87.5% (7/8) of them were read as normal. On the other hand, 33% (4/12) did not receive CT scan of head, and yet three of the four patients were treated for CE. CONCLUSIONS: In our cohort of patients, CT results did not influence CE treatment or lack thereof; most patients with suspected CE were treated with or without head CT findings of CE, indicating that imaging has very little utility in our cohort of patients. In some cases, the use of head CT delayed the onset of treatment for CE.
Asunto(s)
Edema Encefálico , Cetoacidosis Diabética , Edema Encefálico/diagnóstico por imagen , Edema Encefálico/etiología , Niño , Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/diagnóstico por imagen , Cetoacidosis Diabética/terapia , Humanos , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Calcineurin inhibitors (CNIs) are often associated with abnormalities in glucose and lipid metabolism. Tacrolimus is the most potent CNI which is nowadays used almost universally as a part of triple-drug immunosuppression after kidney transplantation. Tacrolimus can cause islet cell damage and decrease in insulin secretion which can lead to post-transplant diabetes mellitus and rarely diabetic ketoacidosis. Although rare, acute pancreatitis has also been implicated by a few case reports to be associated with tacrolimus. However, tacrolimus-induced acute pancreatitis has not been reported in pediatric kidney transplant recipient till date. CASE DESCRIPTION: We report the first case of tacrolimus-induced acute pancreatitis in association with hypertriglyceridemia and DKA in a child early after kidney transplant. The patient was managed with supportive treatment, and tacrolimus was stopped for three days and then switched to cyclosporine-based regimen. The patient became euglycemic within 8 weeks of switching to cyclosporine and did not have any recurrence of pancreatitis. CONCLUSION: Tacrolimus-induced pancreatitis is rare in the setting of kidney transplants and prompt diagnosis and management can lead to a successful outcome.
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Cetoacidosis Diabética/inducido químicamente , Inmunosupresores/efectos adversos , Trasplante de Riñón , Pancreatitis/inducido químicamente , Tacrolimus/efectos adversos , Adolescente , Terapia Combinada , Cetoacidosis Diabética/diagnóstico por imagen , Cetoacidosis Diabética/terapia , Humanos , Masculino , Pancreatitis/diagnóstico por imagen , Pancreatitis/terapia , Tomografía Computarizada por Rayos XAsunto(s)
Diabetes Mellitus , Cetoacidosis Diabética , Hiponatremia , Mielinólisis Pontino Central , Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/diagnóstico por imagen , Humanos , Imagen por Resonancia Magnética , Mielinólisis Pontino Central/diagnóstico por imagen , Mielinólisis Pontino Central/etiología , Puente/diagnóstico por imagenRESUMEN
BACKGROUND: Bedside sonographic assessment of the optic nerve sheath has gained popularity for evaluating intracranial pressure in recent years. OBJECTIVE: To investigate the bedside sonographic measurements of optic nerve sheath diameter (ONSD) and ONSD/eyeball diameter ratios, which are related with cerebral edema (CE), in children with diabetic ketoacidosis (DKA) before and after treatment. METHODS: Children aged 12 months to 18 years, who were diagnosed with DKA were included. The ONSD was measured at 3 mm posterior to the globe in the anterior axial transbulbar view. The eyeball transverse diameter (ETD) and eyeball vertical diameter (EVD) were measured and ratios of ONSD/ETD and ONSD/EVD were calculated. Bedside ultrasound (US) examinations were performed at the beginning and at the end of fluid therapy. RESULTS: About 43 patients were enrolled. About 12 (27.9%) patients had mild, 14 (32.6%) moderate, and 17 (39.5%) severe DKA. At baseline, the ONSD measurements and ratios were significantly higher in severe DKA group than in those with mild or moderate DKA group. All ONSD measurements, ONSD/ETD, and ONSD/EVD ratios at the end of therapy were significantly lower compared with baseline measurements. At the end of therapy, ONSD measurements and ratios were similar among DKA severity groups. CONCLUSION: The ONSD measurements and ratios decreased from the beginning of DKA treatment, which could be considered as an indicator of an increase in intracranial pressure at the time of admission. Ocular US may serve as a promising tool to perform further risk stratification of children with DKA and to identify DKA-related CE.
Asunto(s)
Edema Encefálico/etiología , Cetoacidosis Diabética/diagnóstico por imagen , Ojo/diagnóstico por imagen , Nervio Óptico/diagnóstico por imagen , Pruebas en el Punto de Atención , Ultrasonografía , Adolescente , Niño , Preescolar , Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/terapia , Femenino , Humanos , Lactante , Masculino , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
BACKGROUND: The management of emphysematous pyelonephritis (EPN) includes conservative medical treatment, percutaneous drainage, and surgical resection of the involved kidney. EPN with diabetic ketoacidosis(DKA) is very rare, in which the clinical management of refusing surgical drainage is inexperienced. CASE PRESENTATION: A 34-year-old woman presented with abdominal pain, chills, fever, nausea, vomiting, chest tightness, and shortness of breath. Blood test results were consistent with diabetic ketoacidosis. Urinary computed tomography scan showed multiple stones in the right kidney and lower ureter, with right hydronephrosis. Blood culture demonstrated Escherichia coli bacteremia, and EPN was diagnosed. Considering the need for a second percutaneous nephrolithotomy, the patient refused percutaneous drainage. After continuous intravenous infusion of small doses of insulin and antibiotic treatment, the ketoacidosis resolved. The patient's temperature returned to normal and abdominal pain was alleviated, and liver and kidney functions were also back to normal. After hospital discharge, the patient underwent two percutaneous nephrolithotomy in the department of urology. CONCLUSIONS: EPN with diabetic ketoacidosis should be diagnosed as soon as possible. For patients with Class 1 and Class 2 EPN with diabetic ketoacidosis and urinary tract obstruction, if surgical drainage is refused, it is particularly important to rapidly correct diabetic ketoacidosis and intravenous use of sensitive antibiotics, so as to create conditions for follow-up percutaneous nephrolithotomy.
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Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/diagnóstico por imagen , Pielonefritis/complicaciones , Pielonefritis/diagnóstico por imagen , Adulto , Tratamiento Conservador/métodos , Cetoacidosis Diabética/terapia , Drenaje/métodos , Femenino , Fluidoterapia/métodos , Humanos , Insulina/administración & dosificación , Pielonefritis/terapiaAsunto(s)
Cetoacidosis Diabética/fisiopatología , Hipertensión Intracraneal/patología , Nervio Óptico/patología , Ultrasonografía/métodos , Adolescente , Niño , Preescolar , Cetoacidosis Diabética/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Hipertensión Intracraneal/diagnóstico por imagen , Presión Intracraneal , Masculino , Nervio Óptico/diagnóstico por imagen , Pronóstico , Estudios ProspectivosRESUMEN
Background Cerebral edema is a fatal complication that can occur in children with diabetic ketoacidosis (DKA). Its clinical signs are generally not explicit, and subclinical cerebral edema can occur. This study is one of the few longitudinal studies conducted to identify cerebral edema in patients with DKA by measuring the optic nerve sheath diameter (ONSD). The aim of this study was to investigate cerebral edema in children with DKA with serial measurement of ONSD, which is an early and reliable indicator of cerebral edema, and to monitor changes in ONSD during therapy. Methods The study was conducted by measuring ONSD ultrasonographically at baseline and during the course of therapy in patients with DKA. All participants were diagnosed and received therapy at our unit between May 2016 and June 2017. The study was registered with the Clinical Trials database, with a study number of NCT02937441. Measurements were obtained while the patients were in the supine position with their eyes closed, and axial transbulbar images of both eyes were obtained with a 6-15-MHz linear probe. Results The ONSD values of children with DKA changed during the treatment, reaching the highest values at 12-16 h of therapy, and the greatest ONSD was observed in children who had moderate and severe DKA. Conclusions During treatment of children with DKA, it is possible to predict cerebral edema by measuring ONSD, and this may contribute to clinical management, especially fluid treatment.
Asunto(s)
Edema Encefálico/diagnóstico , Cetoacidosis Diabética/complicaciones , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/etiología , Nervio Óptico/patología , Ultrasonografía/métodos , Adolescente , Biomarcadores/análisis , Glucemia/análisis , Edema Encefálico/diagnóstico por imagen , Edema Encefálico/etiología , Niño , Preescolar , Cetoacidosis Diabética/diagnóstico por imagen , Cetoacidosis Diabética/terapia , Femenino , Estudios de Seguimiento , Hemoglobina Glucada/análisis , Humanos , Lactante , Recién Nacido , Hipertensión Intracraneal/diagnóstico por imagen , Estudios Longitudinales , Masculino , Nervio Óptico/diagnóstico por imagen , Pronóstico , Estudios ProspectivosAsunto(s)
Cetoacidosis Diabética/complicaciones , Hemorragia/complicaciones , Mielinólisis Pontino Central/complicaciones , Adolescente , Cetoacidosis Diabética/diagnóstico por imagen , Femenino , Hemorragia/diagnóstico por imagen , Humanos , Imagen por Resonancia Magnética , Mielinólisis Pontino Central/diagnóstico por imagenRESUMEN
INTRODUCTION: In addition to diffuse brain oedema, diabetic ketoacidosis (DKA) can lead to ischaemic or haemorrhagic stroke, extrapontine myelinolysis, and sinovenous thrombosis. However, posterior reversible encephalopathy syndrome (PRES) and spinal cord oedema are rarely reported in patients with DKA. METHODS: We present a case of a 17-year-old-girl who developed headache, blurred vision, and paraplegia after her DKA was controlled. Sequential magnetic resonance (MR) scans of the brain and spinal cord were performed. RESULTS: Brain MR showed large patchy lesions in the bilateral white matter of the parieto-occipital lobes, which had high T2 signal intensity and low T1 signal intensity. MR scanning of the spinal cord showed longitudinal confluent central spinal cord T2 hyperintensity spanning seven thoracic spinal segments. With symptomatic treatment, the patient's headache and vision disturbance subsided within 1 week. Subsequent MR scans demonstrated that the lesion in the spinal cord had decreased significantly in 10 days, and the large patchy lesions in the brain disappeared completely in 2 months. Her paraplegia improved gradually without obvious sequela 3 months later. The evolution of the disease and radiological findings supported the diagnosis of PRES with spinal cord involvement. CONCLUSION: To the best of our knowledge, this is the first case report describing PRES with spinal cord involvement as a complication of DKA. PRES is a rare complication that should be considered along with other neurological complications of DKA when focal deficits appear.
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Cetoacidosis Diabética/complicaciones , Síndrome de Leucoencefalopatía Posterior/etiología , Médula Espinal/patología , Adolescente , Cetoacidosis Diabética/diagnóstico por imagen , Diuréticos Osmóticos/uso terapéutico , Femenino , Humanos , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Manitol/uso terapéutico , Flebografía , Síndrome de Leucoencefalopatía Posterior/diagnóstico por imagen , Síndrome de Leucoencefalopatía Posterior/tratamiento farmacológico , Médula Espinal/diagnóstico por imagenAsunto(s)
Cetoacidosis Diabética/diagnóstico por imagen , Hipertensión Intracraneal/diagnóstico por imagen , Nervio Óptico/diagnóstico por imagen , Ultrasonografía , Adolescente , Encéfalo , Niño , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico por imagen , Cetoacidosis Diabética/etiología , Femenino , Humanos , Masculino , Pediatría , Proyectos PilotoRESUMEN
OBJECTIVE: Intracranial hypertension is an infrequent but serious acute complication of pediatric diabetic ketoacidosis (DKA). Subclinical elevations of intracranial pressures however, may be more common, and can be indirectly evaluated with ultrasonography of the optic nerve sheath diameter (ONSD). In this pilot study, we report serial data on ONSD trajectories from five pediatric patients with DKA to generate hypotheses for future studies. METHODS: Five pediatric patients with type 1 diabetes presented to our emergency department with DKA and enrolled in our study <3h after initiation of treatment. Ultrasonographic evaluation of the ONSD was conducted at presentation, every three hours until resolution of acidosis, and finally 24h post presentation. Following each interval evaluation, a clinical bedside neurologic tool developed for detecting cerebral edema in DKA was utilized. RESULTS: Four of the five patients exhibited a similar "bell" shaped trajectory - an increase of ONSD after initiation of treatment followed by a return to admission baseline. Patients demonstrated peak ONSDs nine and twelve hours after DKA therapy was initiated, at resolution of acidosis, and at admission. No children exhibited clinical signs suggestive of cerebral edema. CONCLUSIONS: Peak ONSDs cannot be reliability determined in children with DKA unless serial investigations are conducted. Practices to mitigate risks for intracranial hypertension may require constant surveillance during DKA management.
Asunto(s)
Cetoacidosis Diabética/terapia , Hipertensión Intracraneal/diagnóstico , Nervio Óptico/diagnóstico por imagen , Adolescente , Niño , Cetoacidosis Diabética/diagnóstico por imagen , Femenino , Humanos , Masculino , Nervio Óptico/patología , Proyectos Piloto , Reproducibilidad de los Resultados , UltrasonografíaRESUMEN
Diabetic ketoacidosis (DKA) is a state of severe insulin deficiency and a serious complication in children with diabetes mellitus type 1. In a small number of children, DKA is complicated by injury of the central nervous system. These children have a significant mortality and high long-term neurological morbidity. Cerebral edema is the most common neuroimaging finding in children with DKA and may cause brain herniation. Ischemic or hemorrhagic stroke during the acute DKA episode is less common and accounts for approximately 10% of intracerebral complications of DKA. Here we present the neuroimaging findings of two children with DKA and brain injury. Familiarity with the spectrum of neuroimaging findings seen in pediatric DKA is important to allow early detection as well as initiation of therapy and, hence, prevent complications of the central nervous system.
Asunto(s)
Encéfalo/diagnóstico por imagen , Cetoacidosis Diabética/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Tomógrafos Computarizados por Rayos X , Niño , Femenino , HumanosRESUMEN
In the recent years we have been observing an increased incidence of type 1 diabetes in children and adolescents. This leads to a more frequent acute complication of type 1 diabetes among children with hyperglycemia. The most common of these is diabetic ketoacidosis (DKA), while cerebral edema is the most dangerous. In children with DKA, cerebral edema most often presents with clinical symptoms but may also appear in the so-called "subclinical" form. That is why the search continues for new methods of assessing and monitoring cerebral edema in the course of DKA treatment. Ultrasonographic optic nerve sheath diameter (US ONSD) assessment is performed in various clinical scenarios when cerebral edema is suspected. It is most often performed in adult patients but increasingly often in children. US ONSD assessment is useful in the treatment of DKA in children with type 1 diabetes. This manuscript provides an overview of research results available in PubMed and other available databases on the course of treatment of DKA in children with type 1 diabetes.
Asunto(s)
Edema Encefálico/complicaciones , Edema Encefálico/diagnóstico por imagen , Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/diagnóstico por imagen , Nervio Óptico/diagnóstico por imagen , Ultrasonografía , Adulto , Edema Encefálico/epidemiología , Edema Encefálico/fisiopatología , Niño , Cetoacidosis Diabética/epidemiología , Cetoacidosis Diabética/fisiopatología , Humanos , Nervio Óptico/patología , Nervio Óptico/fisiopatología , Tamaño de los Órganos , Ultrasonografía/métodosRESUMEN
BACKGROUND: Wolcott-Rallison syndrome is an autosomal recessive, multisystem disorder with onset of diabetes in the neonatal period or early infancy. CASE REPORT: A 9-year-old girl with diabetes and growth failure from 2 months of age presented with ketoacidosis and multiple organ failure. Evaluation for short stature revealed epiphyseal dysplasia. A homozygous mutation in the EIF2AK3 gene confirmed the clinical diagnosis of Wolcott-Rallison syndrome. She was euthyroid. Biochemical evaluation for potential adrenal dysfunction because of persistently elevated serum potassium (range 5.9-6.3 meq/l) and low serum sodium levels (range 128-130 meq/l) 2 weeks after resolution of ketoacidosis yielded normal findings with respect to basal corticotropin (31 pg/ml) and cortisol (18.7 µg/dl) levels. Estimated GFR-Schwartz (36.9 ml/min/1.73 m(2) ) was consistent with stage 3 chronic renal failure. The transtubular potassium gradient was 1.39 (normal value in hyperkalemic states: > 4.1). The plasma aldosterone (upright: 241.3 pmol/l) was within normal ranges, and plasma renin [39 pg/ml (range 5.41-34.53 pg/ml)] was slightly elevated. The patient was diagnosed as having relative hypoaldosteronism and was started on a sodium-rich diet and low potassium. Failure to respond to the dietary intervention prompted a trial of oral fludrocortisone with subsequent normalization of electrolyte levels. CONCLUSIONS: This is the first case report of Wolcott-Rallison syndrome complicated with relative hypoaldosteronism. Further research is needed to probe the causal inference of relative hypoaldosteronism with chronic renal failure in patients with Wolcott-Rallison syndrome.
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Diabetes Mellitus Tipo 1/complicaciones , Epífisis/anomalías , Hipoaldosteronismo/etiología , Osteocondrodisplasias/complicaciones , Niño , Diabetes Mellitus Tipo 1/diagnóstico por imagen , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Cetoacidosis Diabética/complicaciones , Cetoacidosis Diabética/diagnóstico por imagen , Epífisis/diagnóstico por imagen , Femenino , Fludrocortisona/uso terapéutico , Humanos , Hipoaldosteronismo/diagnóstico por imagen , Hipoaldosteronismo/tratamiento farmacológico , Insuficiencia Multiorgánica/complicaciones , Insuficiencia Multiorgánica/diagnóstico por imagen , Osteocondrodisplasias/diagnóstico por imagen , Osteocondrodisplasias/tratamiento farmacológicoRESUMEN
OBJECTIVES: Subclinical cerebral edema has been reported in pediatric patients with type 1 diabetes and diabetic ketoacidosis (DKA) through magnetic resonance imaging. Ultrasonography of the optic nerve sheath diameter (ONSD) has been used to evaluate intracranial pressure. The objective of this study was to examine the utility of ONSD ultrasonography to evaluate intracranial pressures in children with DKA. METHODS: This prospective cohort evaluated pediatric patients who presented to the emergency department of the Children's Hospital at the University of Manitoba with DKA within 3 hours of initial treatment. A pediatric bedside neurologic evaluation tool for cerebral edema was utilized 1) within the first hour of the intravenous fluid initiation (t=0 hr); 2) 8 hours after initiation of treatment (t=8 hr); and 3) at hours after presentation (t=24 hr). At each time interval, 3 images of the patients' ONSDs were scanned by an 11 MHz linear array transducer. Increased intracranial pressure was considered in all patients whose mean ONSDs were >4.5 mm. RESULTS: We evaluated 7 patients, aged 4 to 17 years. No patients were clinically assessed as having cerebral edema. Overall, no significant differences emerged among the 3 time points (t=0 vs. t=8 hr; t=0 vs. t=24 hr; t=8 vs. t=24 hr) (all p>.216). Effect sizes were small at 0.14 (t=0 vs. t=8 hr); 0.27 (t=8 vs. t=24 hr); and 0.07 (t=0 vs. t=24). CONCLUSIONS: Although not statistically significant, subtle changes in intracranial pressure may have been detected with ONSD ultrasonography in pediatric patients with DKA.
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Diabetes Mellitus Tipo 1/patología , Cetoacidosis Diabética/diagnóstico por imagen , Hipertensión Intracraneal/diagnóstico por imagen , Nervio Óptico/diagnóstico por imagen , Ultrasonografía/métodos , Adolescente , Niño , Preescolar , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico por imagen , Cetoacidosis Diabética/etiología , Cetoacidosis Diabética/patología , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Humanos , Masculino , Nervio Óptico/patología , Proyectos Piloto , Pronóstico , Estudios ProspectivosAsunto(s)
Diabetes Mellitus Tipo 1/complicaciones , Cetoacidosis Diabética/complicaciones , Hipopotasemia/complicaciones , Hiponatremia/complicaciones , Intususcepción/etiología , Intususcepción/patología , Niño , Diabetes Mellitus Tipo 1/diagnóstico por imagen , Diabetes Mellitus Tipo 1/patología , Cetoacidosis Diabética/diagnóstico por imagen , Cetoacidosis Diabética/patología , Femenino , Humanos , Hipopotasemia/diagnóstico por imagen , Hipopotasemia/patología , Hiponatremia/diagnóstico por imagen , Hiponatremia/patología , Intususcepción/diagnóstico por imagen , RadiografíaAsunto(s)
Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/etiología , Absceso/diagnóstico por imagen , Cetoacidosis Diabética/diagnóstico por imagen , Infecciones por Escherichia coli/diagnóstico por imagen , Enfermedades Renales/diagnóstico por imagen , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , UltrasonografíaRESUMEN
Spontaneous pneumomediastinum is a fairly uncommon complication of diabetic ketoacidosis. Knowledge of the clinical and radiographic manifestation is important for the proper management of patients since the disease usually follows a benign evolution. We report a case of a 20-year-old soldier who presented with a pneumomediastinum that was initially falsely attributed to a motor vehicular crash.
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Cetoacidosis Diabética/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Accidentes de Tránsito , Medios de Contraste , Diagnóstico Diferencial , Humanos , Masculino , Personal Militar , Adulto JovenAsunto(s)
Cetoacidosis Diabética/complicaciones , Mucormicosis/diagnóstico , Enfermedades Nasales/diagnóstico , Enfermedades Orbitales/diagnóstico , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/diagnóstico por imagen , Cetoacidosis Diabética/diagnóstico , Cetoacidosis Diabética/diagnóstico por imagen , Progresión de la Enfermedad , Resultado Fatal , Femenino , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Mucormicosis/diagnóstico por imagen , Mucormicosis/etiología , Mucormicosis/patología , Enfermedades Nasales/diagnóstico por imagen , Enfermedades Nasales/etiología , Enfermedades Nasales/patología , Enfermedades Orbitales/diagnóstico por imagen , Enfermedades Orbitales/etiología , Enfermedades Orbitales/patología , Radiografía , Rhizopus/aislamiento & purificación , Rhizopus/fisiologíaRESUMEN
Mr. A.M.A. is 28-year-old Egyptian male patient who presented to the ER with diabetic ketoacidosis (DKA) and left loin pain of 3 weeks duration. The patient had a history of hospital admission 5 months earlier because of urinary tract infection and DKA. Workup of this clinical case revealed emphysematous pyelonephritis.