Unusual Presentation and Complications of New-Onset Type 1 Diabetes in a 3-Year-Old

Abstract

A previously healthy 3-year-old Asian American girl presented to the emergency room with decreased responsiveness following a 3-day history of polydipsia and polyuria. Parents reported that she had been drinking large amounts of milk tea and smoothies as a result of increased thirst. They also reported a viral upper respiratory illness 1 to 2 weeks prior to presentation. The patient had no previous medical problems. On presentation, she was febrile, tachycardic, hypotensive, and tachypneic with diffuse edema, abdominal distension, and comatose with Glasgow Coma Scale score of 3. Laboratory results were significant for glucose of 1383 mg/ dL, a pH of 7.07, a bicarbonate level <7 mmol/L, and anion gap of 30 concerning for diabetic ketoacidosis (DKA). Urinalysis was positive only for trace ketones, serum osmolality of 409 mOsm/kg, and hypernatremia with sodium of 154 mmol/L suggestive of significant volume depletion and hyperosmolar hyperglycemic state (HHS). The patient was found to be in multisystem organ failure including cerebral edema seen on brain computed tomography (CT), pleural effusions, acute liver dysfunction, partial bowel obstruction, oliguric acute kidney injury, pancreatitis, and central hypothyroidism. Abdominal X-ray and CT scan on presentation showed dilation of the small bowel consistent with partial bowel obstruction. She was emergently stabilized with intubation, fluid resuscitation, chest tube drainage, multiple vasopressors (dopamine, norepinephrine, and epinephrine), empiric piperacillin/tazobactam, and clindamycin for presumed septic shock. In addition, an insulin drip and mannitol for cerebral edema due to DKA was administered. She was transferred to our facility and admitted to the pediatric intensive care unit where she had a complicated hospital course requiring continued mechanical ventilation; hemodynamic support with multiple vasopressors; multiple blood, platelet, and cryoprecipitate transfusions; and continuous renal replacement therapy (CRRT). Abdominal ultrasound was significant for dilated fluid-filled bowel loops with wall thickening and adjacent peritoneal free fluid. Surgery team was consulted who felt patient had a medical ileus due to critical illness. A repeat CT scan of head on day 2 revealed hemorrhagic infarctions in the territory of the left posterior cerebral artery and in the posterior aspect of the corpus callosum. The patient was subsequently diagnosed with type 1 diabetes mellitus (T1DM) with a hemoglobin A1c of 10.6%, decreased C-peptide level of 0.3 ng/mL, and positive antibodies to glutamic acid decarboxylase, IA-2 antibody, islet cell cytoplasm, and insulin. Blood, endotracheal tube, and urine cultures on presentation all grew Candida albicans, and the patient was started on a 4-week course of micafungin for disseminated candidiasis. She also remained on empiric piperacillin/tazobactam, which was transitioned to ceftriaxone as she remained afebrile and blood cultures were negative for bacterial growth. Magnetic resonance imaging obtained on hospital day 6 showed decreased cerebral edema and scattered hemorrhagic infarcts in the parietal occipital regions and posterior corpus callosum with normal ventricular system and normal MRA/MRV (magnetic resonance angiography/magnetic resonance venography). She demonstrated significant improvement while on CRRT with Glasgow Coma Scale improved to 11T as well as improving hemodynamic stability, serum osmolality, electrolyte abnormalities, acidosis, liver function, and pancreatitis. Abdominal distention seen on initial presentation was significantly improved and enteral feeds were started via nasogastric tube at a low rate. Feed rate was unable to be titrated up, however, as she developed fecal occult positive diarrhea with increasing rates of enteral feeds. Clostridium difficile toxin assay was obtained and was negative. On hospital day 9, she developed new-onset fevers and an increase in white blood cell count from 7950/μL to 20 000/μL. Physical examination was concerning for pain with left hip flexion and a workup for septic arthritis 884576 CPJXXX10.1177/0009922819884576Clinical PediatricsAnh et al research-article2019