You are working in an ED in Houston when a 2 year old girl presents with fever for one day and decreased po intake. On arrival her temp=103, HR=180, and RR=50 SaO2=100%. She was born in the US and is up to date on all of her vaccinations, but has just returned from a trip to Liberia where she was visiting her extended family and received multiple mosquito bites. Physical exam, CXR and urinalysis are otherwise unremarkable and you suspect malaria, based on her history. You start quinine IV while you are waiting for the smear when suddenly the child becomes unresponsive.
Clinical Question:
What is the next investigation you should perform?
Answer:
Rapid blood glucose!
This patient has at least 4 reasons to be hypoglycemic:
1. fasting (Kids can become hypoglycemic from fasting alone in ~24hrs)
2. infection (any infectious disease can cause it, esp in kids <3 yrs old)
3. malaria (thought to be due in part to increased consumption by parasite)
4. quinine (stimulates insulin release)
Bottom Line:
Kids can become hypoglycemic fast—check a blood glucose in all pre-pubertal sick children.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
References
Zijlmans WCWR et al. Glucose metabolism in children: influence of age, fasting, and infectious diseases. Metabolism Clinical and Experimental. 2009. 58:1356-1365.
