Diabetic ketoacidosis in toddler with a diaper rash

Williams, Mark D. ; Sallee, Don; Robinson, Matthew. The American Journal of

Abstract (summary)
TranslateAbstract
The term diabetes does not denote a single disease entity but rather a clinical syndrome.
Fundamental to all types of diabetes is impairment of insulin secretion by the pancreatic beta cells.
Diabetes is divided into (1) diabetes associated with certain syndromes or conditions, (2) gestational
diabetes, (3) non-insulin-dependent diabetes or type 2 diabetes, and (4) insulin-dependent diabetes
(IDDM) or type 1 diabetes. The impairment of insulin secretion seen in diabetes is due to
progressive loss of pancreatic beta-cell function secondary to an autoimmune-mediated process.
Diabetes mellitus is the most common metabolic disorder of childhood (2). We present a patient with
a common finding in children, diaper candidiasis. Surprisingly, our patient was found to have IDDM
and be in diabetic ketoacidosis.

Full Text
The authors report no source of support for this Case Report presented at the 22nd Annual Local
Academic Research Competition, Naval Medical Center, San Diego, Calif, on April 13, 2009.
A 2-year-old white female patient with no medical history was brought to the emergency department
by her mother because of a progressively worsening diaper rash (see Figs. 1 and 2). The mother
reported that her daughter had been having this rash for more than 10 days. The toddler had been
seen by her primary care provider and prescribed antifungal cream. According to the toddler's
mother, despite using the antifungal cream, the rash continued to worsen. The mother grew more
concerned when the toddler began to lose weight and have increased thirst. On questioning, the
mother denied cough or cold symptoms, fevers, nausea, vomiting, or abdominal pain. The mother
did report polyuria and polyphagia.
Vital signs included temperature of 99.3°C, pulse rate of 123/min, respiratory rate of 32/min, and
weight of 10.5 kg. Physical examination was remarkable for the presence of a severely inflamed
pervasive rash extending from the mons pubis through the perineum and anus, ending at the
sacrum. The history of polyuria, polyphagia, and weight loss prompted a "finger stick" blood glucose
test, which indicated a blood glucose level of greater than 500! Confirmation was required by a
serum glucose measurement. The toddler was started empirically on intravenous fluids, and a
laboratory workup was performed.
Laboratory studies yielded the following values: white blood cell count, 6800/μL with a normal
differential; blood urea nitrogen, 13 mg/dL; creatinine, 0.8 mg/dL; sodium, 126 mmol/L; potassium,
3.7 mmol/L; chloride, 94 mmol/L; carbon dioxide, 12 mmol/L; and glucose, 906 mg/dL. Venous blood
gas values showed a pH of 7.13; Pco 2, 35 mm Hg; Po 2, 46 mm Hg; and bicarbonate, 12 mEq/L. A
bolus of isotonic sodium chloride solution (20 mL/kg) was given intravenously.
The diagnosis of insulin-dependent diabetes mellitus (IDDM) and diabetic ketoacidosis (DKA) was
made. Regular insulin via a continuous infusion was administered at 0.1 U/kg per hour. After
consultation with the pediatric service, the toddler was admitted to the pediatric intensive care unit
(PICU). While in the PICU, the toddler received the appropriate therapy for DKA, had an
unremarkable hospital course, and was discharged after 5 days.
The term diabetes does not denote a single disease entity but rather a clinical syndrome.
Fundamental to all types of diabetes is impairment of insulin secretion by the pancreatic beta cells.
Diabetes is divided into (1) diabetes associated with certain syndromes or conditions, (2) gestational
diabetes, (3) non-insulin-dependent diabetes or type 2 diabetes, and (4) IDDM or type 1 diabetes.
The impairment of insulin secretion seen in diabetes is due to progressive loss of pancreatic beta-
cell function secondary to autoimmune-mediated process. There is a long preclinical period before
the clinical signs and symptoms of diabetes develop. During this period, T cells reacting with beta-
cell antigens can be detected, and the immunologic attack on the beta cells is occurring. Progressive
loss of beta-cell function has been observed months to years before the onset of clinical IDDM. At
least 80% to 90% of the functional capacity of the beta cells must be lost before hyperglycemia
occurs. In genetically susceptible individuals, not only does the pancreas get destroyed by T cells
and other cytokines but insulin secretion has been found to become impaired as well [1].
We present a patient with a common finding in children, diaper candidiasis. Surprisingly, our patient
was found to have IDDM and be in DKA. Diabetes mellitus is the most common metabolic disorder
of childhood [2]. Type 1 or IDDM is caused by relative deficiency of insulin secretion resulting in
abnormal metabolism of carbohydrate (hyperglycemia and glucosuria), fat (hyperlipidemia), and
protein (muscle wasting) [2]. Insulin-dependent diabetes mellitus typically begins between the ages
of 7 and 13 years, but 1% to 3% of patients are younger than 1 year at onset [3]. The diagnosis of
IDDM requires a serum glucose level of greater than 200 mg/dL in a nonfasting patient and greater
than 120 mg/dL in a fasting patient [4]. Up to 30% of patients with newly diagnosed IDDM are initially
found to have DKA [5]. Epidemiological studies have shown that between 1% and 5% of patients
with type 1 diabetes will have an episode of ketoacidosis each year [6].
Diabetic ketoacidosis can result from many acute medical illnesses that change the
counterregulatory hormones to insulin ratio. One of the actions of insulin is to suppress lipolysis in fat
and muscle by inhibition of hormone-sensitive lipase. Insulin deficiency causes accelerated lipolysis,
which releases free fatty acids into the circulatory system; the liver metabolizes them into ketone
bodies, primarily β -hydroxybutarate and acetoacetate. In DKA, the ratio of ketone bodies β -
hyroxybutarate and acetoacetate rises from the normal 1:1 to as high as 3:1 [7]. Children with DKA
usually have a serum glucose level of greater than 300 mg/dL and ketonuria. The serum bicarbonate
level is usually less than 8 mEq/dL, and pH is less than 7.3. The usual symptoms of polyuria,
polydipsia, and weight loss (if present) may go unrecognized. Infants with DKA often have irritability,
vomiting, tachypnea, and dehydration [3,4]. Because infantile DKA is rare, more common illnesses
such as gastroenteritis are considered. As a result, the diagnosis of DKA may be delayed
[8]. Diabetic ketoacidosis has a 5% to 15% mortality rate and causes 70% of all deaths due to IDDM
in children younger than 10 years [2].
Our patient represented for a nonhealing diaper candidiasis. Consideration was given to possible
IDDM as a diagnosis based on her parent's report of weight loss and increased thirst. Diabetic
ketoacidosis was subsequently confirmed. Because of the significant mortality associated with DKA,
any child with a nonhealing diaper candidiasis should be considered for IDDM.
Footnote
The views expressed in this article are those of the authors and do not reflect the official policy or
position of the Department of the Navy, Department of Defense, or the United States Government.
References
Porte D Jr., Sherman RS, Baron A: Ellenberg & Rifkin's Diabetes Mellitus . 6th ed.; New York (NY):
McGraw-Hill Professional, 2002.
Bonadio WA: Pediatric diabetic ketoacidosis: pathophysiology and potential for outpatient
management of selected children . Pediatr Emerg Care 8 287-290, 1992.
Bland GL, Wood VD: Diabetes in infancy: diagnosis and current management . J Natl Med Assoc 83
361-365, 1991.
Brouhard BH: Management of the very young diabetic . Am J Dis Child 139 446-447, 1985.
Grunt JA, Banion CM, Ling L: Problems in the care of the infant diabetic patient . Clin Pediatr 17
772-774, 1978.
Faich GA, Fishbein HA, Ellis SE: The epidemiology of diabetic acidosis: a population-based study .
Am J Epidemiol 177 551-558, 1983.
Laffel L: Ketone bodies: a review of physiology, pathophysiology and application of monitoring to
diabetes . Diabetes Metab Res Rev 15 412-416, 1999.
Harper DE, Waldrop RD: Infant diabetic ketoacidosis in the emergency department . South Med J 89
729-731, 1996.
Word count: 1157
Copyright Elsevier Limited 2010
Indexing (details)
Cite MEDICAL SCIENCES--EXPERIMENTAL
Subject MEDICINE, LABORATORY
Diabetes; TECHNIQUE,MEDICAL SCIENCES--
Insulin; ORTHOPEDICS AND TRAUMATOLOGY
Mortality; ISSN
Hyperglycemia; 07356757
Health care; Source type
Glucose Scholarly Journals
MeSH Language of publication
Child, Preschool, Diabetes Mellitus, Type 1 -- English
drug therapy, Diabetic Ketoacidosis -- drug Document type
therapy, Diaper Rash -- MIS, Journal Article, Case Reports
microbiology, Female, Humans,Hypoglycemic DOI
Agents -- therapeutic use, Insulin -- http://dx.doi.org/10.1016/j.ajem.2008.01.018
therapeutic use,Candidiasis, Cutaneous -- Accession number
complications (major), Diabetes Mellitus, Type 18774050
1 -- diagnosis (major), Diabetic Ketoacidosis -- ProQuest document ID
complications (major), Diabetic Ketoacidosis -- 1030819913
diagnosis (major), Diaper Rash -- Document URL
complications (major) http://search.proquest.com/docview/10308199
Substance 13?accountid=36130
Hypoglycemic Agents; Copyright
Insulin Copyright Elsevier Limited 2008
Title Last updated
Diabetic ketoacidosis in toddler with a diaper 2013-02-19
rash Database
Author ProQuest Nursing & Allied Health Source
Williams, Mark D.; Sallee, Don; Robinson,
Matthew
Publication title
The American Journal of Emergency Medicine
Volume
26
Issue
7
Pages
834.e1-2
Publication year
2010
Publication date
2010
Year
2010
Publisher
Elsevier Limited
Place of publication
Philadelphia
Country of publication
United States
Publication subject