November 3, 2008
Diagnosis and Symptoms
Question from Puebla, Mexico:
A week ago, my 15-month-old daughter woke up lethargic. I took her to the Emergency Room and, after a while there, they checked her urine to find ketonuria (I don’t think there was glucose in the urine). Her blood sugar was 47 mg/dl [2.6 mmol/L]. She was treated with a bolus of glucose and had blood sugars from 285 mg/dl [15.8 mmol/L] (immediately following the bolus) to 212 mg/dl [17.8 mmol/L] seven hours later. Her morning blood sugar may have been 191 mg/dl [10.6 mmol/L](this is uncertain). After being taken off the dextrose I.V. solution, her blood sugar, the following morning, was 67 mg/dl [3.7 mmol/L].
Tests were done on counterregulatory hormones. Everything was normal except that her insulin was 1.0 (low normal value given was 6). During the week, she had one fasting capillary glucose of 59 mg/dl [3.3 mmol/L] and one high of 171 mg/dl [9.5 mmol/L], which was two hours after a sugary snack. Today, she went in for an OGTT and all laboratory work came back completely normal. The highest value, which was at 60 minutes, was 151 mg/dl [8.4 mmol/L]. I believe her two-hour value was 111 mg/dl [6.2 mmol/L] to 119 mg/dl [6.6 mmol/L](I can’t remember exactly). All insulin levels were normal. We are awaiting results later this week for islet cell antibodies and C-Peptide levels, among other things. How likely is it that this could still be diabetes? Do you have any other ideas what might cause these symptoms? I have heard mention, by another endocrinologist, that her body may be “trying to convert” to diabetes. If this were a possibility, could you please explain a bit about this?
Answer:
This does not sound like diabetes, but rather dehydration and perhaps some mild ketotic hypoglycemia that occurs when there is insufficient food/energy provided. This occurs often with a diarrhea illness, but sometimes just any viral illness and insufficient food intake. It is reassuring to hear that the insulin, cortisol and growth hormone levels were checked (the counterregulatory hormones) and that these were normal – especially the low insulin levels at the same time as the low glucose levels. This suggests no insulin overproduction, insulin tumors, nesidioblastosis, etc. The high blood glucose levels could have been errors from drawing directly from the vein getting the intravenous glucose or merely the amount of intravenous glucose being provided at the moment. So, it sounds like you are in good medical hands, they are thinking correctly and ordering the proper tests. I would suggest you go back and discuss this situation with them, decide about future blood glucose monitoring, especially with illnesses, and strategies to help provide energy with future viruses to try to prevent such recurrences. If the islet antibodies were to be positive, this would make me worry about developing diabetes in the future; if they were negative, this wouldn’t help very much since this sometimes occurs with such insensitive antibody tests.
SB
