Clinician’s Corner
Case 2: Generalized swelling in a child with newly diagnosed diabetes mellitus
A
14-year-old girl presented with three months of increasing polydipsia and polyuria. Initial investigations revealed a blood glucose level of 28.4 mmol/L, pH 7.19 and large urine ketones. She was diagnosed with new-onset type 1 diabetes mellitus in diabetic ketoacidosis. She was started on subcutaneous insulin and showed clinical improvement. In the following days, her insulin requirement steadily increased. Ten days after diagnosis, she again presented to the emergency department with a six-day history of progressive swelling of her lower limbs, abdominal distention, joint pain and weakness. There was no history of shortness of breath, oliguria, jaundice or abdominal pain. Her weight had increased 10.2 kg since diagnosis. She had facial and sacral edema, and lower extremity pitting edema up to her calves. Her abdomen was distended with dullness to the flanks, and her liver edge was palpable 4 cm below the costal margin. Heart sounds were normal without S3, S4 or murmurs. Lung fields were clear, without crackles. Deep tendon reflexes were decreased and she had distal weakness. A chest x-ray showed no evidence of pleural effusion, and urinalysis showed no proteinuria. Further investigations and evaluation suggested the etiology of her presentation.
Correspondence (Case 2): Dr Brenden Hursh, BC Children’s Hospital, Endocrine and Diabetes Unit, K4-215, 4480 Oak Street, Vancouver, British Columbia V6H 3V4. Telephone 604-875-3611, fax 604-875-3231, e-mail [email protected] Case 2 accepted November 26, 2013
Paediatr Child Health Vol 19 No 5 May 2014
©2014 Pulsus Group Inc. All rights reserved
233
Clinician’s Corner
CASE 2 DIAGNOSIS: INSULIN EDEMA
When the patient was again admitted to the general pediatric ward of the authors’ tertiary care hospital 10 days after starting insulin for type 1 diabetes mellitus, she underwent tests to elucidate the cause of new-onset edema. Echocardiography was normal, an abdominal ultrasound showed normal Doppler flow and renal anatomy, and her serum albumin and renal and liver function tests were normal. A review of the literature was undertaken, which found numerous reports describing a rare complication of a very common treatment: insulin edema. Insulin edema occurs either at initiation of insulin therapy or with escalation in treatment. Of 16 previously published case reports involving children (
Case 2: Generalized swelling in a child with newly diagnosed diabetes mellitus
A
14-year-old girl presented with three months of increasing polydipsia and polyuria. Initial investigations revealed a blood glucose level of 28.4 mmol/L, pH 7.19 and large urine ketones. She was diagnosed with new-onset type 1 diabetes mellitus in diabetic ketoacidosis. She was started on subcutaneous insulin and showed clinical improvement. In the following days, her insulin requirement steadily increased. Ten days after diagnosis, she again presented to the emergency department with a six-day history of progressive swelling of her lower limbs, abdominal distention, joint pain and weakness. There was no history of shortness of breath, oliguria, jaundice or abdominal pain. Her weight had increased 10.2 kg since diagnosis. She had facial and sacral edema, and lower extremity pitting edema up to her calves. Her abdomen was distended with dullness to the flanks, and her liver edge was palpable 4 cm below the costal margin. Heart sounds were normal without S3, S4 or murmurs. Lung fields were clear, without crackles. Deep tendon reflexes were decreased and she had distal weakness. A chest x-ray showed no evidence of pleural effusion, and urinalysis showed no proteinuria. Further investigations and evaluation suggested the etiology of her presentation.
Correspondence (Case 2): Dr Brenden Hursh, BC Children’s Hospital, Endocrine and Diabetes Unit, K4-215, 4480 Oak Street, Vancouver, British Columbia V6H 3V4. Telephone 604-875-3611, fax 604-875-3231, e-mail [email protected] Case 2 accepted November 26, 2013
Paediatr Child Health Vol 19 No 5 May 2014
©2014 Pulsus Group Inc. All rights reserved
233
Clinician’s Corner
CASE 2 DIAGNOSIS: INSULIN EDEMA
When the patient was again admitted to the general pediatric ward of the authors’ tertiary care hospital 10 days after starting insulin for type 1 diabetes mellitus, she underwent tests to elucidate the cause of new-onset edema. Echocardiography was normal, an abdominal ultrasound showed normal Doppler flow and renal anatomy, and her serum albumin and renal and liver function tests were normal. A review of the literature was undertaken, which found numerous reports describing a rare complication of a very common treatment: insulin edema. Insulin edema occurs either at initiation of insulin therapy or with escalation in treatment. Of 16 previously published case reports involving children (
