Neurological Symptoms at Presentation: What it could be?

Background: Neurological symptoms can have multiple causes, such as structural changes of the central or peripheral nervous system as well as metabolic, hydroelectrolytic or even psychiatric disorders.

Objectives / Methods / Results: A 12-years-old adolescent presented at emergency service (ES) with acute onset of blurred vision, drowsiness, headache and speech difficulties. He was tachycardic but normotensive, emaciated, with slurred speech and dry mouth and objective weight loss of 22% in a week.

Blood test revealed hyperglycemia (glucose 1763mg/dL), moderate metabolic acidosis (pH 7.169, HCO3 - 12.1mmol/L), high blood ketone levels (ketone bodies 7mmol/L), acute renal failure (creatinine 2.3mg/dL, urea 108mg/dL) and sodium level 135mmol/L (corrected sodium 161). Head computed tomography without cerebral edema or structural changes.

Based on results it was made the diagnosis of Type 1 Diabetes mellitus (T1DM). Retrospectively, patient`s mother reported polyuria, polydipsia and polyphagia with several weeks of evolution, and recent pollakiuria that motivated a previous visit to the ES. Fluid therapy and intravenous perfusion of insulin was started. Careful and frequent adjustments were needed, nevertheless he developed important hypernatremia (corrected sodium 175 mmol/L). Progressively, he presented improvement in glycemia, ketoacidosis, renal function and dehydration, with disappearance of neurological symptoms.

Subsequent study with decreased C-peptide and insulin, increased GAD65 and anti-insulin antibody, and normal levels of anti-zinc transporter protein 8 autoantibodies, thyroid function and lipid profile.

At discharge he had no analytic changes. Weight gain of 21%, with no other changes at physical examination.

Conclusion: The elevated glycemia and the consequent hydroelectrolytic disorders following the treatment constituted a challenge. It was important to control the rapid rise in hypernatremia to avoid serious consequences as brain shrinkage, intracerebral hemorrhage and demyelination. This case also alert to the importance to a earlier diagnosis of T1DM and to some less frequent and even confounder symptoms in an inaugural episode.