August 13, 1999
Question from Middlegrove, New York, USA:
My 7 year old son has had fluctuating blood sugars for 3 years now. Lately he has been running low, 30 to 40. In the past two months, we have had 4 episodes of low sugars, swelling of lymph nodes in armpit and groin, night sweats, temperatures of 99.7 to 101F, nosebleeds (he does have Von Willibrand’s [a bleeding disorder]) vomiting of blood (1 episode), some hair loss, itchy skin and stomach pain. CRP level elevated [a lab test for infection], bilirubin elevated and BUN in the 30s, sed rate up to 25, ALP level in the 300’s [all more lab tests], and 8 pounds lost in weight.
Any ideas? We treat him with IV’s when the sugar is low but they say they aren’t sure what is wrong. With the CRP elevated we know we have to keep searching for the source of infection any ideas as to where to look. His doctor is going to contact Children’s Hospital but any ideas until I can get him there would be much appreciated.
I have to say that I did not immediately recognise a specific entity from the complex story you gave and even if you had added some important details, like whether the liver was enlarged, whether there was protein or red blood cells or ketones in the urine, etc., I don’t think I should have done any better. I am however quite sure of two points though. The first is that the basic problem is not any form of diabetes and the second is that your son’s doctor is doing exactly the right thing in trying to get him admitted to the Children’s Hospital. The great advantage of such a setting is first of all that an independent and very thorough history and physical examination can be carried out and then that the expertise of many subspecialty experts can be brought to bear on the problem. They are sure to have different ideas, the metabolic group may think that the hypoglycemia represents a late form of one of the organic acidurias and the gastroenterologists will perhaps think that the evidence of a liver problem might mean lupoid hepatitis and the infectious disease experts again something else. What this cumbersome process nearly always achieves however is an answer even if it means a rather dreary series of sometime negative tests.