The Long Journey to Finding a Treatment that Works: Dante's Story

The path of managing Dante Kladouras’ hyperinsulinism has been a twisting road. His case didn’t fit into any traditional pattern, but the experienced doctors of CHOP’s Congenital Hyperinsulinism Center — working side by side with his parents — found a treatment that has kept him safe.

Kladouras FamilyDante, the biggest of triplet siblings at birth on Nov. 16, 2014, weighed 2 pounds, 12 ounces. His brother Austin was born at 2-7, and sister Tavianna at 1-10. Dante was the first to leave the NICU, going home at 6 weeks old.

He was gaining weight and doing well at home when, on April 24, as his mother, Kija, held him, he turned bright red, then blue, holding his breath and staring. He then took a couple deep breaths and his color came back.

A blood test in the emergency room showed his blood glucose level at a dangerously low 35 mg/dL. Dante was immediately admitted and his lows were managed with IV dextrose while doctors searched for the cause. High insulin levels pointed to hyperinsulinism, and he was treated with diazoxide, octreotide and feedings via a nasogastric (NG) tube, keeping his blood sugar steadily in the mid-60s. Doctors said he was ready to be discharged.

Search for answers leads to CHOP

By then, Kija’s own research showed her “CHOP was THE place for HI,” even though it was across the country from their San Diego home. She spoke with an HI Center nurse practitioner, who told her that CHOP’s protocols didn’t indicate discharge with sugar levels in the mid-60s. Then Dante threw up, dislodging the NG tube. Within 45 minutes, his blood level dropped to 37. “That’s when I told the doctor, ‘We need to go to CHOP,’” Kija says. “I wanted to know I brought Dante to the best place with the best doctors with the best knowledge.” They came to Philadelphia via medical flight on May 22. Genetics testing indicated Dante’s HI was diffuse, but an 18F-DOPA PET scan showed the whole tail of Dante’s pancreas “lit up like a Christmas tree,” Kija says. “We were joyous thinking it was focal disease and he could be cured by surgery.”

But it wasn’t so simple. Surgeon-in-Chief N. Scott Adzick, MD, MMM, warned it didn’t look like a typical focal lesion; the tail was too bulbous. “Dr. Adzick is the one who called it,” says Chris Kladouras, Dante’s father. In about 5 percent of PET scans, what appears to be focal turns out to be diffuse disease.

Pathology didn’t show focal disease either. Dr. Adzick ended up removing 40 percent of Dante’s pancreas. Post-surgery, Dante still had low glucose. But the family and doctors decided on medical management
vs. a second surgery for a near-total pancreatectomy. “With the tail and its abnormal concentration of beta cells gone, we’re hoping he’ll be less affected by HI and even outgrow it,” Kija says.

The original treatment plan was to give Dante octreotide. But another twist presented itself: Octreotide made him vomit and his sugars to plunge into the 40s. So the plan was adjusted to continuous dextrose infusion along with tube feedings and bolus dextrose if needed. Kija was trained in how to manage the pumps, and they went home after five weeks at CHOP.

Medical management after surgery

While medically managing Dante’s HI is challenging — especially with two other babies around — it has allowed Dante to maintain a safe sugar level and keep 60 percent of his pancreas, which could mean he won’t eventually develop diabetes and the lifelong complications that come with it.

“If we have to do something difficult for a few years for him to avoid diabetes, I’ll do it,” Kija says. Since November, Dante has been able to tolerate one shot of octreotide a day, allowing him a four-hour window without all his tubes. “That lets him play with his siblings without us worrying about the cords getting pulled,” Kija says. “He’s rolling over now and getting up on all fours. His physical therapist is pleased with his progress.”

Dante has had a couple of hospitalizations when he had a cold or stomach bug; they seem to compromise his ability to maintain his sugar levels.

“He’s still a really happy baby — even when I check his blood sugar 12 times a day,” Kija says. “He smiles all the time.”

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