A previously healthy 3 year old is brought to the ED with 2-3 days of febrile illness (maximum temp 102.9 rectally), decreased activity and frequent urination without other focal complaints. The patient is PO tolerant and has been asking for water frequently, but eating little solid food. Her mother has noticed that the child’s breath smells “like nail polish remover.” Urinalysis demonstrates large ketones and glucose, without evidence of infection on dipstick or microscopy. Fingerstick blood glucose is checked and found to be 263 mg/dl (14.59 mmol/l), so further studies are drawn. Venous pH is 7.38, chemistry shows normal bicarbonate and anion gap, and repeat fingerstick one hour later (with PO hydration only) is 160 (8.87 mmol/l).
Stress hyperglycemia (SH) is considered to be a benign phenomenon, fairly common in infants and young children up to about age 8. Blood sugar levels can be significantly elevated (over 500 in one case report), with younger age and greater illness severity being correlated to degree of elevation. Stress hyperglycemia can confused with DKA as young children rapidly become ketotic during periods of poor PO intake and physiologic stress, and ketosis and/or hyperglycemia alone can cause an osmotic diuresis resulting in polyuria. The pH, serum bicarbonate and anion gap should not be abnormal in SH, however, it is difficult to determine definitively between SH and initial onset of Type 1 diabetes in the ED setting.
Approximately 10% of children with SH will be positive for islet cell antibodies on lab testing and 2-5% (depending on the study) will go on to develop T1DM at some point in the future, which represents a slightly increased risk from the population baseline annual incidence of 20/100,000.
As long as the child is otherwise appropriate for discharge (PO tolerant, normal anion gap, normal pH), elevated blood sugar does not necessarily indicate admission provided rapid followup can be obtained and the patient’s guardians can comply with strict return precautions. It is helpful to send the patient home with a glucometer and instructions to check fasting and 2 hr postprandial sugars a few times daily until followup. SH should resolve rapidly following resolution of illness.
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