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October 21, 2006

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Question from Randburg, Gauteng, South Africa:

My daughter is two years, seven months old and was diagnosed with diabetes at the age of 14 months. From then until now we have pretty much kept her sugar levels under control. She has been well except for the occasional flu from which she recovered. On October 12, she became paralyzed and catatonic. We tested her blood sugar and it was 4.6 mmol/L [83 mg/dl]. We administered a glucagon shot and rushed her to hospital. In the hospital, she had what looked like an epileptic fit/seizure. Her sugar at this time was around 19.0 mmol/L [342 mg/dl]. She regained consciousness after the fit for a few minutes and then became catatonic again and then seized again. She was given an anti-seizure injection that I think was called epineuton. She regained consciousness but was lame on the left side of her body. That night, she had another seizure pretty much the same (each becoming less powerful). All this time her sugar levels were above 15 mmol/L [270 mg/dl]. They put her on a drip that was constantly administering insulin and glucose as she was not eating. The next day she was very docile and her sugar remained above 15 mmol/L [270 mg/dl]. She was slowly regaining movement on her left side. The next morning, she seemed to be worse again and they said she had probably had another seizure in her sleep, but it was not strong enough to see. They put her on Epilim. Every day, she became stronger on her left side. Our pediatric endocrinologist, at our request, changed her baseline insulin to a more stable insulin. All blood tests, CT Scan, EEG, and MRI scans were negative barring a slight swelling of a grey area on the right of her brain (which could be due to the seizures). It has taken seven days for her to regain full strength on the left. With the new baseline insulin, we are going through trial and error to get the right dosages, but we will get this right as we have done it before. I checked her sugar levels over the last three weeks to see if maybe a constant HI might have caused this, but her sugar was well below 15 mmol/L [270 mg/dl] with an occasional level higher than that as she has two older siblings who occasionally leave their food lying around. What do you think happened? My daughter's blood sugar was not too low, hadn't been high over a long period of time, and all tests, as I mentioned, were negative or inconclusive.

Answer:

From your detailed descriptions, it could have been hypoglycemia for some time before the first seizure that was unrecognized. This is quite common. The prolonged and recurring seizures suggest that perhaps this may be a separate seizure disorder/epilepsy situation and I would favor this diagnosis whether or not “triggered” by a falling glucose level. The seizures associated with hyperglycemia also suggested a separate neurological problem like epilepsy. Either way, I would usually favor anti-seizure medications for two years. If she remains seizure free and if EEGs sequentially checked remain entirely normal as well as neurological exam entirely normal, then you would taper off after two years and see if she can remain seizure free. You should stay in close contact with the pediatric diabetes team and also with the pediatric neurologists to follow her clinical course since it will likely help to figure this out. It sounds like they have done all the correct testing and treatment at present and there was nothing that was done incorrectly in the first place as well.

SB