1. Morning meeting -Case discussion
Int. 吳政哲

2. 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(-)

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

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

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

6. 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+)

7. 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 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%

8. 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

9. 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

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

11. 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

12. impression
Bacterial sepsis
Severe viral infection

13. In NICU-7/24

14. 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:

15. 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

16. 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

17. 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. : , ,
GLU 77
T.P.
129
LACT
2.2
Pleocytosis: Monocyte and lymphocyte predominate

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

19. 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

20. 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)

21. 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

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

23. 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

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

25. Discussion
-Neonatal Hyperglycemia

26. MANAGEMENT
Reduction of glucose infusion rate
Insulin therapy 

27. 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.

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

29. 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