Facial droop and confusion overtake teen boy

Key Points

The Case

You are working in the emergency department one Sunday morning when an emergency medical services team brings in a 15-year-old boy with weakness and disorientation. The boy's father reports that he found his son in the kitchen that morning and noted that he seemed to have difficulty speaking and a left-sided facial droop.

The boy said that he was hungry but had difficulty filling a bowl of cereal because of incoordination. His parents gave him some Gatorade, which he struggled to drink. He subsequently had tensing of his right leg. At that point, the parents called emergency medical services; on arrival, they found that the patient had a blood glucose of 48 mg/dL. The technicians administered an ampule of intravenous (IV) dextrose 50% (D50) and then brought the patient to the hospital for further evaluation.

The results of the head CT are normal. A neurology consult is obtained, and the neurologist orders a magnetic resonance imaging (MRI) scan for further evaluation. Before the MRI scan, the patient's blood glucose is tested again; the result is 56 mg/dL. While the patient is undergoing the MRI scan, an endocrinology consult is requested because of the patient's persistent low glucose levels. On returning to the emergency department, the patient is again hypoglycemic, with a plasma glucose level of 36 mg/dL.

WHAT NEXT?

The patient is feeling much better now and is able to answer questions. He states that he has been in his usual state of health. On the day before these events, he played a baseball game. He reports he ate a typical dinner, had no bedtime snack, and went to sleep as he normally would. When you question him alone, he denies any illicit substance use. He reports that he has not taken any medications surreptitiously. He denies having any episodes like this in the past, and there is no family history of hypoglycemia or related problems.

Physical examination now reveals an alert and oriented young man whose vitals are stable. He is in the 75th percentile for height and weight for his age. His neurologic examination shows no deficits. Cardiovascular, chest, and abdominal examinations are normal. The patient is noted to be pubertal on genitourinary (GU) examination. Skin examination shows no lesions or hyperpigmentation.