Morning meeting -Case discussion Int. 吳政哲

Personal information Name: 陳O森 Chart number: 170585** Age: 28-day-old Gender: male Birth hx: GA 37+6wks, NSD at 婦兒安LMD BBW: 2221g(SGA), DOIC(-), PROM(-)

Chief complaint Fever up to 38.7 degrees for 2 days(7/23-7/24)

Present illness 1st Admission to 新樓 Discharge 2nd Admission Discharge 07/01 07/20 07/21 07/22

Present illness Transfer to NCKUH 3rd Admission Discharge 07/23 07/24 08/02

1st Admission to 新樓 hospital(7/1-7/20) intermittent fever up to 38.7 degrees, metabolic acidosis with respiratory alkakosis, hyperglycemia (up to 851mg/dl), glycosuria (3+), and ketouria(1+)

1st Admission to 新樓(7/1-7/20) Treated with regular insulin: novorapid(0.21U IVP), then euglucon(1/3 Q12H) glucose level was around 100-250 mg/dl (from 851mg/dl) Lab Data: Insulin: < 0.5mU/L, C-Peptide(EIA): <0.05ng/ml, anti-GAD Ab: <1 U/ml, HbA1C < 3.9%

2nd Admission to 新樓 hospital(7/21-22) mild fever up to 37.6 degrees Dextrose level of 179 mg/dl feeding and appetite was generally well

3rd Admission to 新樓 hospital(7/23-24) Fever up to 38.7 degrees, with hyperglycemia (320mg/dl) Tachypnea, Tachycardia, Desaturation Contact hx of enterovirus patient Transfer to NCKUH CSF showed leukocytosis (WBC: 993/cu) Emperic: ampicillin and claforan

Admission to NCKUH- Level II cyanosis with mild subcostal retraction  transfered NICU

PE T：攝氏38.9度,P：182/min,R：58/min,BP：75/32mmHg cyanosis with mild subcostal retraction Ill-looking conjunctiva: no swelling, sclera: anicteric Neck: supple, no JVE, no LAP Chest: symmetric, bil. Clear No heart murmur Skin: no rash, no edema, petechiae or ecchymosis Limbs: no rash

impression Bacterial sepsis Severe viral infection

In NICU-7/24

In NICU-7/24 pH 7.38 PCO2 41.2 HCO3 23.8 BE -1.3 Na 132.6 K 3.95 Ca 1.262 dex 159 Hct 25.5 Microgas:

In NICU-7/24 Septic workup CBC/DC WBC 10.7 RBC 2.21 Hb 7.2 Hct 21.5 MCV 97.2 MCH 32.5 MCHC 33.4 RDW 18.1 Plt 454 Blast Pro Myelo Meta Band Seg 50 Eos Baso Mono 8 Lymph 42 Aty-lym NRBC RI < 2%, with anemia indicates loss of red blood cells, but decreased production of reticulocytes (i.e., an inadequate response to correct the anemia) and therefore red blood cells

In NICU-7/24 Septic workup Biochemistry BUN 2 CREA 0.40 eGFR / AST 29 ALT 12 BIL-T 0.9 BIL-D 0.2 LD 276 CRP 8.3 LD: >1000 Bil: high

In NICU-7/24 CSF Septic workup H.In B Negative N.Menigi ACYW135 N.Menigi B/Ecoli K1 S.Pneu. Strept.B Appear. Clear RBC 160 WBC 730 SEG. 18 EOS. BASO. MACRO/MONO 43 LYM. 37 ATY-LYM. 2 MESOTHEL Septic workup Gluc : >50 T.P. : 50-80, 80-150, 100-300 GLU 77 T.P. 129 LACT 2.2 Pleocytosis: Monocyte and lymphocyte predominate

In NICU-7/24 Hyperglycemia Urine Blood Ketone Negative Glucose (random) 172 Blood

In NICU-7/24 Empirical antibiotics with Ampicillin and Claforan Hb=7.2 blood transfusion with PRBC Cardiac echo: no abnormal finding Brain echo: slightly increased ventricular lining echogenicity

In NICU-7/25-7/26 Fever subsided on 7/26 According to above data, viral meningitis was most likely Kept Ampicillin and Claforan(meningitis dose)

In NICU-7/27-28 Coxsackievirus B 5: (+) in CSF, throat/ anal swab B/C(-),CSF: (-) Stop antibiotics supportive care Transfer to Level II on 7/28

In Level II Condition stable Arrange surveys for the hyperglycemia Arrange surveys for the recurrent infection

Surrveys Neonatal hyperglycemia: Insulin < 0.5mU/L C-Peptide(EIA) <0.05ng/ml anti-GAD AB: <1 U/ml HbA1C < 3.9% Neonatal hyperglycemia: ---Insulin and c-peptide, and GAD Ab r/o type 1 DM Recurrent infection ---IgG, IgA, IgM, IgE and cell marker of CD3/CD19/CD4/CD8/HLA- DR/CD57/CD3-/(CD16+56)+ for immunodeficiency

In Level II Hyperglycemia=298 (07/31) , 187(08/01) Glibenclamide 5mg/tab (Gliben) x 4 days

Discussion -Neonatal Hyperglycemia

MANAGEMENT Reduction of glucose infusion rate Insulin therapy 

Causes Parenteral administration of glucose - Prematurity - Sepsis - Stress Drugs Neonatal diabetes mellitus - Transient - Permanent Drugs --glucocorticoid therapy 6q24-related transient neonatal diabetes mellitus (6q24-TNDM) The cardinal features are: severe intrauterine growth retardation, hyperglycemia that begins in the neonatal period in a term infant and resolves by age 18 months, dehydration, and absence of ketoacidosis.

Casuse Transient neonatal DM- ---70% caused by 6q24 aberrations ---resolves by age 18 months ---severe intrauterine growth retardation, dehydration, no ketoacidosis

Casuse permanent neonatal DM ---first appears within the first 6 months of life and persists throughout the lifespan ---KCNJ11 and ABCC8 ---severe intrauterine growth retardation, dehydration, failure to thrive