December 11, 2008
Diagnosis and Symptoms
Question from Louisville, Kentucky, USA:
When we originally took our son to the Emergency Room (ER) on the November 11, 2008, he was having difficulty breathing. When we got to the ER, his heart rate was up about 150 to 160, his respiration rate was 70 to 80, and he was getting oxygen but his oxygen was staying at 95 percent. They did blood work, stated that he was probably diabetic and that the symptoms that he was experiencing were probably a reaction to the diabetes; he had not been diagnosed until this incident. They did not say whether his sugar was high or low. The ER doctor wanted him admitted, but when they contacted the endocrinologist’s office, they were saying that it was stress induced hypoglycemia and not diabetes and that he didn’t need to be admitted. They asked us to check his sugar at home for a couple days and to call the endocrinologist to whom we were referred in a couple days with the results.
The office called us on Friday, November 14, and asked us to bring our son into the office so that he could have laboratory work done. They said to feed him normally and to continue testing his blood sugar until we get the results back.
On November 18, we took our son him to the ER again because he had started vomiting that day, had diarrhea, was very lethargic and would not eat or drink anything. Every time he did try to eat or drink, he would immediately vomit it back up. They tested his urine and he did have a small amount of ketones in his urine, but they said it was probably from him not eating. They did a blood count. They said that his red blood cell count was normal, but his white blood cell count was a little low which indicated that he probably had a viral infection. They gave him something to settle his stomach and sent him home where he continued with not eating or drinking, vomiting and diarrhea and just was generally lying around and sleeping a lot.
Because our son wouldn’t wake up on Friday the 21st, we had to call 911. His blood sugar was 47 mg/dl [2.6 mmol/L]. We tried to give him orange juice to bring it back up but he just vomited it right back up. The EMTs gave him some sort of glucose from a tube and his sugar came up to 88 mg/dl [4.9 mmol/L] at the hospital. The hospital contacted the endocrinologist’s office. A different endocrinologist said that our son’s tests had come back negative and that he may or may not have diabetes, that he may just be in the early stages and has not started producing the antibodies. The treated him for dehydration by giving him fluids, gave him something to settle his stomach and discharged him.
The next morning, he did get sick one time and had a little more diarrhea. But, he was back to acting normal eating and drinking, and his activity level has increased. He was still thirsty all the time and said that he was tired all the time.
He has yet to be seen by any doctor besides a ER physician because he doesn’t have a pediatrician at the moment since he just goes to the local health clinic for check-ups. He went to the endocrinologist’s office, but only to have blood drawn, and they have yet to even see him or his blood sugar reading from home. All of our conversations with people in the office have either been over the phone or through the hospital.
Obviously, there is something going on. I am afraid that if we don’t get it sorted out, we might end up in a bad situation if his sugar gets too high or low again.
So, can you help us understand what might be going on with our son?
Should it be relevant, both his grandmothers are living and have diabetes, although I am not sure which type. One takes pills, the other takes insulin. My wife’s grandparents also had it.
Blood Sugar Levels:
Date
Time
Blood Glucose
11/12/08
12:35 p.m.
233 mg/dl [12.9 mmol/L]
12/12/08
3:14 p.m.
193 mg/dl [10.7 mmol/L]
11/12/08
6:35 p.m.
280 mg/dl [15.6 mmol/L]
11/12/08
10:12 p.m.
250 mg/dl [13.9 mmol/L]
11/13/08
7:57 a.m.
69 mg/dl [3.8 mmol/L]
11/13/08
12:38 p.m.
114 mg/dl [6.3 mmol/L]
11/13/08
7:50 p.m.
255 mg/dl [14.2 mmol/L]
11/13/08
11:27 p.m.
180 mg/dl [10.0 mmol/L]
11/14/08
7:59 a.m.
122 mg/dl [6.8 mmol/L]
11/14/08
12:09 p.m.
98 mg/dl [5.4 mmol/L]
11/14/08
5:35 p.m.
157 mg/dl [8.7 mmol/L]
11/15/08
8:15 a.m.
91 mg/dl [5.1 mmol/L]
11/15/08
1:24 p.m.
96 mg/dl [5.3 mmol/L]
11/15/08
6:30 p.m.
143 mg/dl [7.9 mmol/L]
1/15/08
10:50 p.m.
185 mg/dl [10.3 mmol/L]
11/16/08
8:13 a.m.
108 mg/dl [6.0 mmol/L]
11/16/08
12:34 p.m.
241 mg/dl [13.4 mmol/L]
11/16/08
6:56 p.m.
119 mg/dl [6.6 mmol/L]
11/16/08
10:51 p.m.
144 mg/dl [8.0 mmol/L]
11/17/08
8:25 a.m.
214 mg/dl [11.9 mmol/L]
11/17/08
1:57 p.m.
89 mg/dl [4.9 mmol/L]
11/17/08
7:04 p.m.
135 mg/dl [7.5 mmol/L]
11/17/08
10:35p.m.
145 mg/dl [8.0 mmol/L]
11/18/08
10:07 a.m.
110 mg/dl [6.1 mmol/L]
11/18/08
5:20 p.m.
121 mg/dl [6.7 mmol/L]
11/19/08
10:01 a.m.
77 mg/dl [4.3 mmol/L]
11/19/08
1:14 p.m.
198 mg/dl [11.0 mmol/L]
11/19/08
7:48 p.m.
123 mg/dl [6.8 mmol/L]
11/20/08
12:33 a.m.
201 mg/dl [11.2 mmol/L]
11/20/08
9:13 a.m.
89 mg/dl [4.9 mmol/L]
11:20/09
12:47 p.m.
174 mg/dl [9.7 mmol/L]
11/20/08
7:46 p.m.
148 mg/dl [8.2 mmol/L]
11/20/08
10:26 p.m.
125 mg/dl [7.0 mmol/L]
11/21/08
8:53 a.m.
47 mg/dl [2.6 mmol/L]
11/21/08
3:44 p.m.
160 mg/dl [8.9 mmol/L]
11/21/08
7:39 p.m.
83 mg/dl [4.6 mmol/L]
11/22/08
8:14 a.m.
110 mg/dl [6.1 mmol/L]
11/22/08
2:38 p.m.
126 mg/dl [7.0 mmol/L]
11/22/09
6:40 p.m.
127 mg/dl [7.1 mmol/L]
11/22/08
10:24 p.m.
137 mg/dl [7.6 mmol/L]
11/23/08
9:08 a.m.
267 mg/dl [14.8 mmol/L]
11/23/08
12:53 p.m.
210 mg/dl [11.6 mmol/L]
11/23/08
8:29 p.m.
131 mg/dl [7.3 mmol/L]
Answer:
I think what is most confusing is how/why the physician in the ER had initially told you that the child had diabetes, given that apparently, despite the breathing issues, the doctor did not confirm for you that the blood glucose was high. Indeed, in the next sentence, you wrote that the consulting endocrinologist thought the child had experienced “stress induced HYPOglycemia.” (Emphasis mine.)
If this were true, then diabetes would seem to NOT be the cause. But, perhaps, there is a misunderstanding and what was meant was stress induced HYPERglycemia. Yet, diabetes does not typically have diarrhea as a presenting symptom. Much more classically, there is increased thirst and urination both day and night. Often, there is weight loss. Furthermore, the various glucose values you report don’t “scream” diabetes to me either, but some are a bit suspicious.
The presence of ketones in the manner you describe certainly is consistent with what we commonly call “starvation ketosis,” which is a common, natural phenomenon when we don’t eat well. Indeed, apparently the boy’s glucose was LOW at that time. This does NOT suggest diabetes to me. Given the repeated ER visits, I would be surprised that glucose levels were not (re-)measured. And, if they were not high, then this probably would not be diabetes.
I think that you should indeed make an appointment for a full history and physical examination with a pediatrician or family doctor who is accustomed to working with young people. Your only seeking ER visits for the health care is not only expensive, but the same doctor rarely gets to see your child repeatedly.
I also would recommend that you carefully review the technique of your glucose checks. Which glucose monitor are you using? Does it require calibration or matching of the code strips to the meter? If so, you must be certain that the meter code is adjusted to the strips, or you will get false values. Where did you get this meter? Who instructed you in its use?
Given the family history that you provided, your child may have some increased risk for the future development of diabetes. Don’t assume that the pancreatic antibody tests were done. The results should be available by now. Call, but keep in mind that antibodies do not make or exclude the diagnosis. I bet the doctor also did a hemoglobin A1c (HbA1c) and if elevated, this would be a little suspicious, too.
Let us know what you learn.
DS
