Bell Palsy as an Atypical Presenting Symptom of Type 2 Diabetes Mellitus
Eric Sales, MD; Kathryn Tierling, MD; Angela S. Byrd, MD; and Emily L. Klepper, MD
Our Lady of the Lake Children’s Hospital and Pediatric Residency Program, Baton Rouge, Louisiana
Sales E, Tierling K, Byrd AS, Klepper EL. Bell palsy as an atypical presenting symptom of type 2 diabetes mellitus [published online August 28, 2018]. Neurology Consultant.
An obese 14-year-old boy presented to the emergency department (ED) with a 2-day history of left cheek pain and drooping of the left side of his face. He also reported a 2- to 3-month history of polyuria, polydipsia, and a 15.4-kg weight loss. At presentation, he had mild altered mental status with slowed mentation.
Physical examination. The patient was afebrile (temperature, 37°C) and had a heart rate of 97 beats/min, a respiratory rate of 14 breaths/min, blood pressure of 126/98 mm Hg, and a body mass index of 31 kg/m2. He had an asymmetric smile with left-sided drooping, an inability to puff out the left cheek, and left eye ptosis. He also had loss of forehead and eyebrow movement of the left side. Neck examination revealed hyperpigmentation of the posterior neck consistent with acanthosis nigricans.
Cardiac examination revealed normal S1 and S2 with no murmurs, gallops, or rubs. The lung fields were clear to auscultation bilaterally with no rales, rhonchi, or wheezing. The abdomen was soft, nontender, and nondistended, with normal bowel sounds. Sensation was intact throughout, with normal motor function in all extremities.
Diagnostic tests. Laboratory test results obtained in the ED were significant for a blood glucose level of 569 mg/dL; urinalysis revealed a glucose level greater than 1000 mg/dL and a ketone level of 20 mg/dL. Results of a complete blood cell count with differential and venous blood gas testing were within normal limits. Results of a comprehensive metabolic panel showed a blood glucose level of 761 mg/dL and an anion gap of 12 mEq/L. The glycated hemoglobin concentration was elevated at 17.1%.
Based on his clinical presentation and diagnostic test results, the patient received a diagnosis of new-onset diabetes mellitus without diabetic ketoacidosis and Bell palsy (idiopathic peripheral nerve palsy).
Treatment. The patient was given a normal saline bolus and was started on insulin glargine, 40 U daily at bedtime; insulin lispro, 1 U for every 10 g of carbohydrates consumed with meals and snacks; and a sliding-scale correction of 1 U of insulin lispro for every 40 mg/dL above a blood glucose level of 160 mg/dL.
Further workup to differentiate type 1 diabetes mellitus (T1DM) vs type 2 diabetes mellitus (T2DM) included assays for immunoglobulin A antibodies, tissue transglutaminase antibodies, glutamic acid decarboxylase antibodies, complement-fixing islet cell autoantibodies, and islet cell immunoglobulin G autoantibodies, the results of which all were normal, confirming the diagnosis of T2DM. Corticosteroids were not given due to their potential to induce further hyperglycemia. Acyclovir was not started, since there was no clear indication that a prior viral infection had precipitated the facial palsy. Diabetes management was continued with the addition of metformin, 1000 mg twice daily.