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Forum Name: Pediatric Topics

Question: Type 1 diabetic following ruptured appendicular abscess (


 wuhdyl - Tue Nov 22, 2005 6:13 pm

My son ( the patient) aged 13 had an emergency admission for acute
abdominal pain. Abdominal Ultrasound showed appendicular abscess,
Haematology white cells 7000 . All other indices normal apart from
raised blood glucose 12mmo/l & crp 20. there was no history of raised
blood sugar levels in the blood tests done previous to the
appendicectomy and no family history of Diabetes

Keyhole appendicectomy was performed within 6 hours for a perforated
appendix , the pathology was inflammatory cells and no carcinoid .
Post operative there was fever 39-40 C treated by i.v. antibiotics .
Blood sugar continued to be high and increased at the end of 7 days to
22-24 mmo/l and ketones in the urine. Subcutaneous soluble insulin was
started , the temperature dropped after 1 week.

The patient was discharged on Augmentin orally, soluble insulin X 3
and lantus insulin in the evening. Since the operation ( August ) the
patient has complained of persitent nausea which is present till now
and not responding to antacids or anti nausea medication . The
temperature recurred on stopping the antibiotics and the blood glucose
level shot up to 24-28 mmo/l inspite of the insulin. Several courses
of antibiotics have been given but the temperature keeps recurring
after stopping the antibiotics.

Abdominal ultra sound was normal , Abdominal Cat scan was normal apart
from thickening at the jejunodeodunal juntion. The white blood count
has dropped from 7000 to 2900 with atypical Lymphocytes, Hb, RBC,
Platelets, ESR normal , no Lymphadenopathy , Eccocardiography normal ,
white blood cell study showed pooling of white blood cells in the left
side of the Colon.

Serology lyme disease, Mycoplasma all negative , Antibody screening negative.

Patient history, Tonsillectomy at the age of 4 , cyst of Morgagni
removed at the age of 11

Has there been any similar cases reported and documented in reputable
medical journals and what would be the next step in the management
of this case .
 Dr. Heba Ismail - Mon Nov 28, 2005 8:26 am

Diabetes is often precipitated by any acute stressful condition, such as an appendicular abscess as in your son's condition. Also, diabetes may have appeared first but was undiagnosed causing a suppression in your child's immunity and thus allowing the abscess to form.
Type 1 or juvenile-onset diabetes is known to occur without a positive family history, although certain gene factors do play a role. As for the nausea, it is common if blood sugar is not properly controlled, in addition to, in your son's case, the prolonged oral antibiotic medications irritating his stomach.
Now, you must understand that a viscious circle has been created here. Uncontrolled blood sugar will predispose to infection, and uncontrolled infection will worsen blood sugar control and so on. The low WBC count is probably due to prolonged antibiotic use, as diabetes would impair the function of WBCs but would not decrease their number.
I suggest tight control of blood sugar, and if the fever does not exceed 38.5, to control it with antipyretics only. A normal ESR is usually against the presence of a serious bacterial infection requiring antibiotics.
I also believe new cultures need to be drawn from blood, urine and stools.
Also, the possibility of a fungal infection has not been excluded as I see from the lab studies done.
Discuss these points with your doctor and please keep us informed with the updates.

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