An 8-year-old boy is brought to the emergency department after 3 days of vomiting, diarrhea, and high fevers. He has had no changes in weight, urine output, or oral intake. The patient has mild persistent asthma for which he takes inhaled fluticasone twice daily and inhaled albuterol as needed. His family history includes a maternal grandmother with type 2 diabetes mellitus. Temperature is 39.4 C (103 F), blood pressure is 70/30 mm Hg, pulse is 176/min, and respirations are 34/min. BMI is 20 kg/m². Examination shows a sleepy-appearing child with dry mucous membranes, prolonged capillary refill, hyperactive bowel sounds, and soft and nontender abdomen. Initial laboratory results are as follows: Which of the following is the most likely explanation for this patient's hyperglycemia? A)Cushing's syndrome B)Inhaled corticosteroid use C)Stress hyperglycemia D)Type 1 diabetes mellitus E)Type 2 diabetes mellitus

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c134_671a_8f63_8b3c4da47c38_MD0005_00 This patient, with hyperglycemia and ketoacidosis in the setting of sepsis with fever, hypotension, dehydration, and tachycardia, most likely has stress hyperglycemia. Stress hyperglycemia is defined as transiently elevated blood glucose levels in the context of severe illness in patients without known diabetes mellitus. During illness and stress, hyperglycemia can result from the release of high levels of stress hormone (eg, cortisol, catecholamines, pro-inflammatory cytokines). Risk factors for stress hyperglycemia include severe illness, temperature >39 C (102.2 F), sepsis, meningitis, and admission to the intensive care unit. Stress hyperglycemia is associated with increased morbidity in critically ill patients. In hyperglycemic critically ill adult patients, glucose-containing intravenous fluids are minimized and insulin is administered to achieve a blood glucose target of 140-180 mg/dL. For hyperglycemic critically ill children, the optimal blood glucose target range and data on insulin therapy are inconclusive. No relationship between stress hyperglycemia and persistent abnormal glucose metabolism or subsequent diagnosis of diabetes mellitus has been demonstrated. This patient's hemoglobin A1c is normal and rules out chronic hyperglycemia. In addition, this patient has no history of weight loss, polyuria, polydipsia, or polyphagia and does not meet the diagnostic criteria for diabetes mellitus(Choices D and E). In the absence of classic symptoms of diabetes or elevated hemoglobin A1c, this patient's hyperglycemia is best explained by stress hyperglycemia in the setting of illness. diagnostic criteria for diabetes mellitus (Choice A) Cushing's syndrome involves glucocorticoid excess and typically presents with obesity, skin changes including atrophy and striae, glucose intolerance, and hypertension. This patient has no hypertension and a BMI of 20 kg/m², making Cushing's syndrome an unlikely cause of his hyperglycemia. (Choice B) Although oral corticosteroids can lead to exogenous glucocorticoid excess and glucose intolerance in the setting of Cushing's syndrome as explained above, significant systemic absorption is rare with proper use of inhaled corticosteroids with a spacer at typical doses. Improper use of inhaled corticosteroids or prolonged high doses has been associated with adrenal suppression, cataracts, and growth deceleration. Educational objective: Stress hyperglycemia is a potential complication of severe illness (eg, sepsis). It is associated with increased morbidity risk and is caused by high circulating stress hormones (eg, cortisol, catecholamines). References: Standards of medical care in diabetes-2011. (http://www.ncbi.nlm.nih.gov/pubmed/21193625) Stress hyperglycemia in febrile children: relationship to prediabetes. (http://www.ncbi.nlm.nih.gov/pubmed/21519318) Stress hyperglycemia in pediatric critical illness: the intensive care unit adds to the stress! (http://www.ncbi.nlm.nih.gov/pubmed/22401321)

An 8-Year-Old Boy Is Brought to the Emergency Department After