Acute Esophageal Necrosis as a Cause of Pneumomediastinum in a Patient With Diabetic Ketoacidosis

A 36-year-old man with type 1 diabetes was admitted to intensive care unit because of acute respiratory distress. He had a 3 day history of general malaise, vomiting, and diarrhea. On physical examination, the patient was hypotensive (relative risk 100/60 mm Hg), tachycardic (110/min), dyspnoeic (peripheral oxygen saturation of 93%), and signs of subcutaneous emphysema of the neck. Laboratory results demonstrated metabolic acidosis (pH 7.03), hyperglycemia (667.8 mg/dL), acute kidney injury (creatinine 2.7 mg/dL; baseline 0.86 mg/dL), leukocytosis (32.13 10), and increased C-reactive protein (70 mg/L). Hemoglobin was normal (16.5 g/dL). He was intubated shortly after admission. Contrast-enhanced computed tomography (CT) demonstrated an extensive pneumomediastinumwith pneumopericardiumand subcutaneous emphysemaof the anterior thoracic wall andneck (Figure 1). The esophageal wall was diffusely thickened and hypodense. Thoracic CT with ingestion of oral contrast demonstrated no leakage of