May 2, 2006
Hyperglycemia and DKA
Question from Lehigh Acres, Florida, USA:
My 16 year old daughter has had type 1 since the age of three and a half. She has had multiple hospitalizations for hyperglycemia and DKA since she turned 12, with an excessive amount over the past one and a half years. She has a history of juvenile rheumatoid arthritis (JRA), but no flare-ups to cause problems and GERD with esophageal ulcers and gastritis found via esophagogastroduodenoscopy (EGD). She is 5 feet, 6 inches and weighs 135 pounds, so weight is not her problem. No one can determine the cause of her frequent episodes. She has had amenorrhea since October 2005 and is scheduled for a gynecological exam.
The doctors who have cared for her during hospitalizations have various reasons for the causes of her problems. One doctor at Miami Children’s Hospital stated he did not think she took her Lantus and that I should draw it up and administer it to her. That was not true as, on most occasions, I witnessed her taking her injection in the evening. Another doctor at Children’s Hospital of Southwest Florida feels she has an eating disorder, but she tries to eat balanced meals and does not show any signs of having an eating disorder. She occasionally has problems with GERD, but it has improved. When her blood sugars have gone high we have tried all the usuals, new bottles and new batches of insulin, covering with extra NovoLog for ketones, hydrating with plenty of water, checking frequent blood sugars and covering every two hour. During her last hospitalization, my daughter had almost 200 units of NovoLog during the day and nothing brought her blood sugars down. She even had blood sugars go into the 500s mg/dl [over 27/8 mmol/L] while on an insulin drip in the PICU. There was no evidence of infection. Her CBC and comprehensive metabolic panel (CMP) were normal, urinalysis was normal. They kept her hospitalized for four days, then everything normalized with no explanation why. Any input?
Answer:
Major stress can do this and cause recurrent episodes of DKA. Sexual abuse is high on my list of suspicious events and often co-exists with severe eating disorders, bulimia and anorexia. With diabetes, omitted insulin often masquerades as such and thus the suspected diagnosis of missing insulin doses. The only guaranteed way to know if this is the case is not to say that a parent watches the insulin but to have the parent actually draw up and physically administer every single insulin dose for two or three months time. In my experience, all episodes of recurrent DKA are “cured” in this fashion. Also, in my experience, very few parents want to believe that their own child/teen is capable of such subterfuge. The real answer, however, is not that omitted insulin causes recurrent episodes of severe DKA, but that the enormous risks that one episode of DKA may be so severe that brain damage or death may occur. So, there is some urgency in getting a correct diagnosis and “fixing” this problem.
SB
