Hemiparesis and Altered Mental Status in a Child After Glyburide Ingestion

doi:10.1016/S0736-4679(98)00010-9

The Journal of Emergency Medicine

Volume 16, Issue 3, May–June 1998, Pages 433-435

https://doi.org/10.1016/S0736-4679(98)00010-9 Get rights and content

Abstract

A normally healthy 6-year-old woke in an agitated state, limp, and moving only her left extremities. Upon arrival at the emergency department, a blood glucose measurement was 34 mg/dL. The child was lethargic, not responding to questions appropriately, and not moving her right extremities. The right arm was flexed, and the right leg was flexed and abducted. Pupils were equal and reactive, and eyes were deviated to the left. Six loose tablets of the grandmother’s glyburide were found at home in the child’s outdoor playhouse. Administration of glucose produced no change in the child’s clinical condition. Intravenous glucose was begun at 4 mg glucose/kg/min, and the blood glucose level did not fall below 74 mg/dL after that. Over the next 48 h, the hemiparesis and mental status changes resolved without sequelae. The events of the case suggest a hypoglycemia-induced seizure with subsequent Todd’s paralysis. Early direct medical evaluation in suspected glyburide ingestions in children is suggested.

Introduction

Accidental sulfonylurea ingestion in children is a common occurrence. For the 5 years from 1990 through 1994, there were 7193 cases of accidental exposure to sulfonylureas in children under 6 years of age reported to poison centers 1, 2, 3, 4, 5, 6. However, serious adverse outcomes have been rare. Two recent large studies describe 278 sulfonylurea ingestions in children, with the only significant findings being the laboratory changes of low blood glucose and transient central nervous system depression 7, 8. No seizures or neurologic sequelae were noted. This lack of serious outcome may have been due to early assessment and treatment. Cases of sulfonylurea-induced neurologic sequelae have universally been associated with cases of delayed recognition of the ingestion (12–48 h) and subsequent prolonged periods of hypoglycemia without treatment 9, 10, 11, 12, 13. We report a case of accidental sulfonylurea ingestion in a child with delayed recognition of the ingestion and subsequent neurologic toxicity, including prolonged mental status changes and right-sided hemiparesis.

Section snippets

Case Report

A 6-year-old female was in her usual state of health until 6 PM the evening prior to admission when she complained of a headache and was put to bed. Her mother took her temperature, and she was afebrile. On the morning of admission, the patient woke in an agitated state. She was limp, moving only her left extremities, and responses to questions were inappropriate.

The patient was transported by the emergency medical service to the local emergency department, where she was found to be lethargic,

Discussion

In our patient, the clear lateralization of the findings suggests that the areas of the brain were not affected equally. One possible explanation for these focal effects is that they are the result of a hypoglycemia-induced seizure. A similar patchy involvement of the central nervous system has been previously reported with sulfonylurea overdose 9, 10. The reason for this asymmetrical involvement is not clear. An expected response to systemic hypoglycemia would be a global involvement rather

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Distinguishing characteristics of exposure to biguanide and sulfonylurea anti-diabetic medications in the United States
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For example, Gunaratne et al. reported a 56 year old man with new-onset hypoglycemia, lethargy, and confusion following unintentional sulfonylurea exposure [31]. Moreover, Spiller et al. reported a lethargic 6-year-old girl with agitation and hypoglycemia after glyburide ingestion [32]. Prior studies documenting clinical manifestations of metformin and sulfonylurea poisoning have been comprised of a small numbers of patients [33,34].
Biguanides and sulfonylureas are anti-hyperglycemic drugs commonly used in the United States. Poisoning with these drugs may lead to serious consequences. The diagnosis of biguanide and sulfonylurea poisoning is based on history, clinical manifestations, and laboratory studies.
This study is a six-year retrospective cohort analysis based on the National Poison Data System. Clinical effects of 6183 biguanide and sulfonylurea exposures were identified using binary logistic regression.
The mean age of patients with biguanide and sulfonylurea exposure was 39.27 ± 28.91 and 28.91 ± 30.41 years, respectively. Sulfonylurea exposure is most commonly seen via unintentional exposure, while biguanide exposure frequently occurs as a result of intentional ingestion. Minor and moderate outcomes commonly developed following biguanide and sulfonylurea exposure, respectively. Sulfonylurea exposure was less likely to develop clinical effects abdominal pain, metabolic acidosis, diarrhea, nausea, vomiting, and elevated creatinine than patients ingesting biguanides. However, sulfonylurea exposure was more likely to cause dizziness or vertigo, tremor, drowsiness or lethargy, agitation, diaphoresis, and hypoglycemia.
Our study is the first to use a wide range of national data to describe the clinical characteristics that differentiate the toxicologic exposure to biguanides and sulfonylureas. Sulfonylurea exposure is commonly seen via unintentional exposure, while metformin exposure is frequently seen via intentional exposure. Sulfonylurea toxicity is more likely to cause agitation, dizziness or vertigo, tremor, diaphoresis, and hypoglycemia, while metformin exposure induces abdominal pain, acidosis, diarrhea, nausea, vomiting, and elevated creatinine.
Are one or two dangerous? Sulfonylurea exposure in toddlers
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Sulfonylurea-based oral hypoglycemics are in widespread use in the adult population, increasing the potential for unintentional exposure in children. This article examines the risk of toxicity in children under 6 years of age who ingest one to two tablets of a sulfonylurea. We review the literature on sulfonylurea toxicity, including cases reported to the American Association of Poison Control Centers (AAPCC). The ingestion of one to two sulfonylurea tablets by a small child can lead to profound hypoglycemia with severe sequelae if untreated. As a result, all potential sulfonylurea ingestions by young children should be evaluated by a physician. A capillary glucose level must be rapidly determined at presentation and should then be repeated at regular intervals for up to 8 hours. A longer observation period is recommended for the extended release preparation of glipizide. Asymptomatic children who do not develop hypoglycemia within the recommended observation period may be safely discharged home. All children who exhibit clear symptoms of hypoglycemia or glucose levels < 60 mg/dL should be admitted for supplemental glucose (oral or intravenous), with careful observation of clinical condition and monitoring of serum glucose levels. In cases refractory to intravenous glucose, therapy with octreotide or diazoxide may be beneficial.
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A more likely explanation is a hypoglycemic-induced seizure with subsequent Todd's paralysis, a brief postictal paralysis of a body part involved in a focal seizure. Spiller et al10 describe a case of a child who presented with hypoglycemic hemiplegia. With immediate normalization of glucose, the focal neurological deficit persisted for 48 hours before complete resolution.
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¹: Toxicology is coordinated by Kenneth Kulig,MD, of Denver, Colorado

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Original ArticlesHemiparesis and Altered Mental Status in a Child After Glyburide Ingestion 1

Abstract

Introduction

Section snippets

Case Report

Discussion

Am J Emerg Med

Am J Emerg Med

Am J Emerg Med

Am J Emerg Med

Am J Emerg Med

J Pediatr

J Pediatr

Prospective multicenter study of sulfonylurea ingestion in children

J Pediatr

Original Articles
Hemiparesis and Altered Mental Status in a Child After Glyburide Ingestion ¹