Six-year-old with altered mental status

A previously healthy 6-year-old child presented to our emergency department after a brief seizure associated with hypoglycemia. The differential diagnosis of hypoglycemia can often lead to excessive testing and initiation of unnecessary therapies. It is well-known that alcohol ingestion can lead to hypoglycemia and potentially seizure in children and should be considered in pediatric patients with altered mental status. However, this child's presenting ethanol level was normal. Nonetheless, there were multiple clues that this was the most likely the following diagnosis: hypoglycemia, mild metabolic ketoacidosis with no osmolar gap, and transient lactic acidemia. Ultimately, review of further history made this the most likely diagnosis. This case emphasizes that despite lacking the evidence of an elevated blood ethanol level at presentation, toxic ingestion of ethanol should still be suspected in cases of altered mental status and hypoglycemia.