INTRODUCTION: Diabetic ketoacidosis(DKA) is a prothombotic state that is frequently observed as the presentation of new onset diabetes mellitus. Aortic arch thrombus has been rarely reported in patients with normal aortic wall architecture. We report the first case of aortic arch thrombus complicating DKA in the presence of normal aortic wall.
CASE PRESENTATION: A 53 year Afro-Caribbean man with no significant medical history presents to the emergency department with a chief complaint of nausea, vomiting, polyurea, polydypsia and weakness for the three days prior to admission. The patient was admitted to the MICU with new onset diabetes and DKA. On hospital day two the patient was symptomatically improved, and his DKA resolved. Just prior to transfer the nurse reports BP of 40/17 mmHg and informs the house-staff. The patient was found awake, alert, in no distress and without new complaints. On exam he was found to have cool upper extremities with absent radial pulses bilaterally but normal carotid and lower extremity pulses. Blood pressures taken from the lower extremities were found to be 130's/80's. The remainder of the exam was unchanged from admission. A stat bedside echocardiogram showed a mobile mass most likely representing a thrombus present at the transition from the transverse to descending aorta. His ejection fraction was normal. A CT aortogram showed a large filling defect in the distal ascending aorta extending into the aortic arch along its inferior wall without definite evidence of an intimal flap or pulmonary emboli. Additionally there were smaller filling defects found in the left axillary artery. He was anticoagulated with heparin and was transferred to cardiothoracic surgery service. On the following day thrombectomy was performed. Ten days later the patient was discharged home. Preliminary hypercoaguability work up was sent prior to administration of heparin. The patient’s lupus anticoagulant was positive. The pathological reports was consistent arotic thrombus.
DISCUSSIONS: Diabetic ketoacidosis (DKA) has been shown to be a prothombotic state. The risks of thrombus formation are increased by treatment of DKA are thought to be due to a relative deficiency of free protein C and protein S and a relative increase in von Willebrand Factor (vWF) which in turn activates vascular endothelium(1). Thoracic aortic mobile mural thrombus (TAMT) is a rare condition that is usually seen in elderly patients with extensive atherosclerotic disease, trauma or a hypercoaguable state. Most reported cases have been associated with atherosclerotic plaque with superimposed thrombus formation and are usually detected following cerebral, visceral or peripheral embolization(2). Our patient was a middle aged male that had been previously healthy. He had no personal or family history of DVT or abnormal clotting and his coagulation profile was normal on admission. His preliminary hypercoaguability work up revealed a positive lupus anticoagulant, without any consequences to date. The effect of hyperviscosity due to osmotic diuresis combined with alterations in the clotting cascaded caused by DKA and its treatment resulted in the formation of a large aortic arch clot in an individual who was already at risk. This case represents the perfect storm that was created by a predisposed individual whose risk was increased by an acquired prothombotic state created by DKA.
CONCLUSION: DKA is a hypercoaguable state. Clot formation can precipitate or complicate DKA. A high degree of suspicion is necessary to identify and treat such life threatening complications.
DISCLOSURE: Joseph Gorga, No Financial Disclosure Information; No Product/Research Disclosure Information