Fatigue - Soccer

Abstract

HISTORY: 9 year old female soccer player with 2 week history of fatigue. At the onset of symptoms, she had just finished an active winter with basketball and skiing and was beginning her soccer season. During the past 2 weeks, she had gone to bed earlier than normal and on occasion was more irritable and emotional. The week prior to her visit with her physician, her parents noticed she was having early satiety with meals. She felt like she was not hungry when she was supposed to be hungry. For example, she was not hungry for dinner but would be hungry during recess. She also decreased her activity level and started to have trouble with simple physical tasks such as going up stairs. This decreased activity tolerance was intermittent. She denied fever, chills, headache, sore throat, ear pain, cough, chest pain, difficulty breathing, abdominal pain, polyphagia or polydipsia. She did admit to feeling more stress lately due to standardized testing at school but otherwise no new life stressors. PHYSICAL EXAMINATION: Appeared thinner than on previous visits with some skin dryness but no acute distress. Her growth chart placed her near the 5 % for height and weight. Vital signs normal. Ear, nose and throat exam normal. Lungs were clear and heart had a regular rate and rhythm with no murmur. Abdomen was soft, non-tender and was positive for mild left lower quadrant fullness. No organomegaly and rest of exam normal. She had shotty posterior cervical and inguinal lymph nodes, but no dominant node. DIFFERENTIAL DIAGNOSIS: Malignancy Anemia Viral Syndrome Mononucleosis Overtraining Diabetes Mellitus Malnutrition TEST AND RESULTS: · Urinalysis: 2000 + glucose, moderate ketones, rest normal · Serum ketones negative · Endomysial Antibody IgA + · t-transglutaminase (tTG) IgA 448 (range 34-305) · CBC: Hct 45.1, MCV 77, rest normal · Comprehensive metabolic panel: Glucose 639, Sodium 128, Chloride 88, rest normal · TSH: normal · Monospot: negative FINAL WORKING DIAGNOSIS: Diabetes Mellitus Type I TREATMENT AND OUTCOMES: Started on long acting insulin daily with a regular insulin sliding scale. She was also found to have Celiac disease. She has had significant improvement in her symptoms since beginning insulin and has returned to playing all sports. She plans on transitioning to the insulin pump in the near future and is currently on a gluten free diet.