What's Your Diagnosis? Pediatric Diabetes

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Substance Use in Adolescents: Recognition and Management in the Emergency Department right.

Case Presentation: Pediatric Diabetes: Management of Acute Complications in the Emergency Department

A 3-year-old previously healthy girl presents to the ED with fatigue and vomiting…

The girl’s parents tell you she has had increased thirst and appetite over the last 6 weeks but has lost 2 kg since her last check-up.

She developed a runny nose and cough yesterday and a fever of 101°F, which has resolved. Today, she began vomiting and became fatigued.

Upon arrival to the ED, the girl is alert, but given her pale and fatigued appearance in triage, she was immediately taken to a room. Her vital signs are: temperature, 37°C; heart rate, 132 beats/min; blood pressure, 70/40 mm Hg; respiratory rate, 31 breaths/min; and oxygen saturation, 100% on room air. Her examination is notable for pallor and ill appearance. She has dry and cracked lips and is breathing fast, with clear lungs. She has epigastric tenderness, but otherwise her abdominal examination is normal.

You can tell this patient is ill, and her history is concerning. What treatment will you initiate to immediately address her shock?

Case Conclusion

You were worried about dehydration, shock, and electrolyte abnormalities in addition to new-onset diabetes and possible DKA. Immediate IV access and laboratory studies were obtained, including a point-of-care glucose and venous blood gas with lactate and electrolytes, which were most notable for a glucose of 385 mg/dL, pH of 7.0, bicarbonate of 8 mEq/L, and lactate of 2.2 mmol/L. The girl was diagnosed with new-onset DKA triggered by a viral illness. While her IV lines were obtained, you were able to obtain additional blood to send to the laboratory for testing, including a complete blood count; hemoglobin A1C; beta-hydroxybutyrate; comprehensive metabolic panel that included calcium, magnesium, and phosphorus levels; lipase; C-reactive protein; serum osmolality; and diabetes diagnostic panel.

The patient also gave a sample for a urinalysis. Prior to receiving the results, you initiated a 20-mL/kg 0.9% NaCl IV bolus to reverse her shock and then a 2-bag system with a continuous 0.05 unit/kg/hr insulin infusion (because you were worried she would be sensitive to insulin), while the front desk clerk paged the endocrinologist on call. You also remembered to evaluate the etiology of her fever and vomiting and were reassured that she did not have pneumonia, appendicitis, intussusception, or pancreatitis, based on your examination and workup. Though she was alert and improved, she was admitted to the pediatric ICU, given her young age and new-onset diagnosis of diabetes mellitus with DKA.

While in the pediatric ICU, she developed some change in behavior and thus received 0.5 g/kg of IV mannitol. A subsequent head CT was normal, but her treatment team was glad they had given her the mannitol. She returned to her clinical baseline and was discharged home with insulin and close endocrinology follow-up.