Introduction: Neurologic symptoms, such as cerebral edema, stroke, and extrapontine myelinolysis, are rare in pediatric patients with type 1 diabetes mellitus (T1DM) in the absence of severe diabetic ketoacidosis (DKA) or chronically poor glycemic control. Ischemic or hemorrhagic stroke may account for 10% of intracerebral complications of DKA. DKA increases the risk for neurovascular compromise by several proposed mechanisms, including dehydration, hyperosmolarity, tissue hypoxia and acidosis. Neurologic complications of hyperglycemia in adult patients without DKA are reported frequently; however, there are rare reports of hyperglycemia without DKA and stroke in the pediatric population.
Case: We present the case of a ten year old, premenarchal, previously healthy, thin African American female, who presented to the emergency department with a two day history of right facial droop and right hemiplegia. Imaging showed an acute right thalamic ischemic stroke without vascular defects. An incidental finding of hyperglycemia (initial blood glucose 217 mg/dl, 12 mmol/l) led to the diagnosis of new onset T1DM with a hemoglobin A1c of 8.4%, positive GAD-65, ICA512, insulin autoantibodies. She did not have ketosis (bicarbonate of 24 mmol/l, negative urine ketones) and her screening for prothrombotic conditions was negative. Family history was negative other than a brother with sickle cell trait. She was treated with multi-dose insulin injection therapy. She returned to her neurologic baseline gradually over the subsequent year without stroke recurrence to date, two years later, despite suboptimal glycemic control due to nonadherence.
Discussion: Stroke at T1DM presentation is rare, especially in pediatric patients and in the absence of DKA. We are aware of only one other report of stroke in a child at diagnosis of diabetes without concurrent DKA, who had thiamine-responsive megaloblastic anemia that may have contributed to her clinical presentation. Hyperglycemia has been implicated in stroke risk but typically in association with concurrent comorbidities such as severe acidosis, metabolic syndrome, and dehydration. Our case does not prove causality, but raises questions about the impact of recent onset hyperglycemia on stroke risk in pediatric patients. Therefore, we propose that diabetes care providers should consider early screening for stroke symptoms in pediatric patients with diabetes (including those without DKA), as prompt diagnosis and treatment of stroke decreases morbidity and mortality.
27 - 29 Sep 2018
European Society for Paediatric Endocrinology