Paralysis in an Adolescent
Paralysis in an Adolescent
An 18-year-old male with a history of diabetes presented with hemiparesis. His serum glucose was low, but did not fit the numerical criteria for hypoglycemia. His symptoms rapidly reversed after glucose infusion. This case illustrates crucial features of hypoglycemia. Symptoms may be atypical in the young adult population and may occur at levels higher than numerical definitions. Clinicians should be vigilant regarding the variability in symptoms of hypoglycemia and serum levels necessary to produce them. Lack of vigilance can lead to delayed critical intervention. Understanding this aspect of hypoglycemia also has implications for training prehospital personnel.
An 18-year-old male with a history significant only for diabetes mellitus type 1 was brought to the emergency department by Emergency Medical Services (EMS) in the morning with complaints of right-sided paralysis and slurred speech. He was in his usual state of health the night before. Before going to bed, his glucometer reading was 240 mg/dL. He was habitually compliant with home glucose monitoring, and his usual glucose level as checked by home glucometer was 180 mg/dL in the morning and 200 mg/dL in the evening. He recalled skipping dinner the evening prior and his last meal, a large sandwich, was at 3 pm the previous day. He skipped dinner because he was not hungry. He was compliant with his insulin regimen and took insulin aspart 70/30 at a dosage of 60 U in the morning, and 60 in the evening. Because he skipped a meal, he reduced his evening dose to 50 U.
When he woke up seven hours later, he couldn't lift his right leg or his right arm. He tried to move out of bed but slid onto the floor due to paralysis. He called for his parents, who also noted that his speech was slurred.
The patient denied any other symptoms including headache, fever, shakes, chills, palpitations, hunger, polyuria or polydipsia. He further denied dyspnea, abdominal pain, nausea, and vomiting. There was no change in his dietary habits, and no other stressors. His endocrinologist last saw him a month before, when his insulin regimen was adjusted. On further history, he denied any similar episodes in the past, despite taking his insulin occasionally late at night or having irregular meals. He had been diagnosed with type 1 diabetes at age 10. The patient denied any alcohol or recreational drug use. His family history was significant only for type 1 diabetes; there was no seizure history in the family. A review of systems was otherwise negative.
Prehospital, EMS reported his vital signs, including blood pressure, respirations, and heart rate, as normal. A glucose check on scene revealed a level of 57. Upon arrival at the emergency department, a quick physical examination revealed an oriented and coherent male with normal vital signs who had mild slurring of speech and right-sided body weakness, with a motor strength of 3 of 5. Repeat bedside glucose check was 61 mg/dL. Twenty-five grams (50 mL) of dextrose 50% solution was immediately pushed, and within one minute, there was a complete improvement of motor strength to 5 of 5, and the slurring of speech disappeared. Further workup revealed normal chemistries except for a hemoglobin A1c of 9.3%. Imaging studies using computed tomography scan, magnetic resonance imaging (MRI), magnetic resonance angiography of the brain and neck were also unremarkable. Electroencephalograph was normal.
Abstract and Case Report
Abstract
An 18-year-old male with a history of diabetes presented with hemiparesis. His serum glucose was low, but did not fit the numerical criteria for hypoglycemia. His symptoms rapidly reversed after glucose infusion. This case illustrates crucial features of hypoglycemia. Symptoms may be atypical in the young adult population and may occur at levels higher than numerical definitions. Clinicians should be vigilant regarding the variability in symptoms of hypoglycemia and serum levels necessary to produce them. Lack of vigilance can lead to delayed critical intervention. Understanding this aspect of hypoglycemia also has implications for training prehospital personnel.
Case Report
An 18-year-old male with a history significant only for diabetes mellitus type 1 was brought to the emergency department by Emergency Medical Services (EMS) in the morning with complaints of right-sided paralysis and slurred speech. He was in his usual state of health the night before. Before going to bed, his glucometer reading was 240 mg/dL. He was habitually compliant with home glucose monitoring, and his usual glucose level as checked by home glucometer was 180 mg/dL in the morning and 200 mg/dL in the evening. He recalled skipping dinner the evening prior and his last meal, a large sandwich, was at 3 pm the previous day. He skipped dinner because he was not hungry. He was compliant with his insulin regimen and took insulin aspart 70/30 at a dosage of 60 U in the morning, and 60 in the evening. Because he skipped a meal, he reduced his evening dose to 50 U.
When he woke up seven hours later, he couldn't lift his right leg or his right arm. He tried to move out of bed but slid onto the floor due to paralysis. He called for his parents, who also noted that his speech was slurred.
The patient denied any other symptoms including headache, fever, shakes, chills, palpitations, hunger, polyuria or polydipsia. He further denied dyspnea, abdominal pain, nausea, and vomiting. There was no change in his dietary habits, and no other stressors. His endocrinologist last saw him a month before, when his insulin regimen was adjusted. On further history, he denied any similar episodes in the past, despite taking his insulin occasionally late at night or having irregular meals. He had been diagnosed with type 1 diabetes at age 10. The patient denied any alcohol or recreational drug use. His family history was significant only for type 1 diabetes; there was no seizure history in the family. A review of systems was otherwise negative.
Prehospital, EMS reported his vital signs, including blood pressure, respirations, and heart rate, as normal. A glucose check on scene revealed a level of 57. Upon arrival at the emergency department, a quick physical examination revealed an oriented and coherent male with normal vital signs who had mild slurring of speech and right-sided body weakness, with a motor strength of 3 of 5. Repeat bedside glucose check was 61 mg/dL. Twenty-five grams (50 mL) of dextrose 50% solution was immediately pushed, and within one minute, there was a complete improvement of motor strength to 5 of 5, and the slurring of speech disappeared. Further workup revealed normal chemistries except for a hemoglobin A1c of 9.3%. Imaging studies using computed tomography scan, magnetic resonance imaging (MRI), magnetic resonance angiography of the brain and neck were also unremarkable. Electroencephalograph was normal.
