Tiroides

Case Report

J C lin Res Pediatr Endocrinol 2011;3(4):222- 224
DOI: 10.4274/jcrpe.373

Tuberculous Meningitis Associated with Diabetic
Ketoacidosis
Özlem Nalbantoğlu Elmas1, Ayşehan Akıncı1, Pelin Bilir2
1Inönü

University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey
University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey

2AnkaraIntroduction
Diabetic ketoacidosis (DKA) is a life-threatening acute
complication of type 1 diabetes mellitus (T1DM). Infection,
trauma, myocardial infarction, surgery are some of the
conditions which lead to an increase in insulin requirements
and thus to DKA (1). During the treatment of DKA, the
patient’s neurological status may show impairment with
symptoms of confusion, lethargy, stupor, or evencoma.
Cerebral edema is the commonest cause of morbidity and
mortality during the first day of treatment for DKA in pediatric
patients (2). Although cerebral edema is the commonest
cause of abnormal neurology in a child with DKA, other
possibilities such as hemorrhage, thrombosis, and/or
intracranial infection should also be considered.

Case Report
ABSTRACT
Diabetic ketoacidosis (DKA) is alife-threatening acute complication of
type 1 diabetes mellitus. Infections are the leading cause of DKA, but
trauma, myocardial infarction, or surgery may also precipitate this
condition. In patients with DKA, although cerebral edema is the most
common cause of neurological symptoms, other possibilities such as
meningitis or encephalitis should also be considered. Herein, we present
the case of an8-year-old girl with DKA and tuberculous meningitis.
Key words: Diabetic ketoacidosis, type 1 diabetes mellitus, tuberculous
meningitis
Conflict of interest: None declared
Received: 09.06.2011

Accepted: 10.10.2011

An 8-year-old girl with T1DM was admitted to the hospital
with fever, lethargy, anorexia, and vomiting. She was
diagnosed three years ago and had been on insulin therapy
(four dailyinjections) since. According to the history obtained
from her family, she had experienced nausea, vomiting, fever,
lethargy, and headache for the last 24 hours. There was no
history of previous neurological disease. On physical
examination, her temperature was 38.1˚C, pulse rate was 112
beats/min, and respiratory rate was 30/min. She had
Kussmaul respiration and was mildly dehydrated. Her historyrevealed no BCG vaccination. On neurological examination,
lethargy and irritability were observed. There were no signs of
meningeal irritation.

Address for Correspondence
Ayşehan Akıncı MD, Inönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey
Phone: +90 422 341 06 60 Gsm: +90 532 643 53 50 E-mail: aakinci@inonu.edu.tr
©Journal of Clinical Research in PediatricEndocrinology, Published by Galenos Publishing.

222

Nalbantoğlu Elmas Ö et al.
Tuberculous Meningitis Associated with DKA

Laboratory Findings
On initial laboratory examination, the patient’s hemoglobin
level was 15.5 g/dL. C-reactive protein (CRP) level was 5
mg/dL. Leukocyte count was 36 100/μL and differential count
showed a shift to the left with toxic granulations in neutrophils.
Bloodglucose level was 444 mg/dL. Metabolic acidosis was
present with a pH of 7.19. The other biochemical values were
as follows: blood urea nitrogen level: 16 mg/dL, serum
creatinine: 0.86 mg/dL, sodium: 124 mmol/L, potassium: 3.6
mmol/L, chloride: 102 mmol/L, serum osmolarity: 312
mOsm/kg. Hemoglobin A1c was 8.1%. The patient’s urine
was strongly positive for sugar and ketones.
Management and Course
DKAtreatment was started with intravenous fluids and
insulin infusion. In view of the presence of fever, elevated CRP
and elevated white blood cell count with neutrophilia,
antibiotics were also started. Plasma glucose was monitored
regularly. During the course of treatment, bradycardia
developed and the lethargic state progressed to stupor.
Cranial computed tomography (CT) scan displayed cerebral...