June 18, 2010
Diagnosis and Symptoms
Question from New Jersey, USA:
My three and a half-year-old son has been toilet trained since September 2009. He was fine, having about one accident per week. Starting in April of this year, he started having three or four accidents on a daily basis. I had him tested for a UTI and his doctor found he had blood in his urine. At that time, my son had a mild case of bronchitis so he was put on antibiotics. About two weeks later, he was still having frequent accidents and his cough showed no improvement so I took him back to the doctor. They found blood in his urine again so the doctor gave us an order for blood work, which showed his carbon dioxide level was less than 5. They thought this was a laboratory error so we took him for more blood work. When he went for blood work, he was on prednisolone for his cough (he also has asthma). His blood glucose level was 350 mg/dl [19.4 mmol/L] compared to the 85 mg/dl [4.7 mmol/L] on his first test. We were sent to the Emergency (ER) and he was admitted to the hospital for three days. When we were in triage in the ER, his glucose level was 313 mg/dl [17.4 mmol/L]. About three hours later, his glucose level was 68 mg/dl [3.8 mmol/L]! While in the hospital, his levels were all over the place, ranging from 68 mg/dl [3.8 mmol/L] to 308 mg/dl [17.1 mmol/L]. They did the antibodies test with the following results: Insulin Antibody – 20 (range is 0 to 5); Anti-GAD – 0.8 (range is less than.5); and Antipancreatic Islet Cell – 1:256 (range is less than 1:1). We have been testing his blood sugar daily since then and his numbers are fairly normal, with some low (58 mg/dl [3.2 mmol/L] before lunch) to some high (225 mg/dl [12.5 mmol/L] two hours after dinner). His endocrinologist said she’s not ready treat him because his numbers are not consistently high. Besides for my grandmother and her sister, there is no family history of diabetes. I have rheumatoid arthritis, so could the autoimmune part be genetic? I also wanted to add that my son is still having several accidents daily, even though his blood sugar is not always high. What is your opinion?
Answer:
Unfortunately, with these positive pancreas antibodies, it looks like your son has very early type 1 autoimmune diabetes mellitus as his diagnosis. It was probably brought on by the illness and/or the steroid treatment but either could be precipitating factors. Because he still has some residual pancreas function, that would likely explain the sometimes okay and sometimes abnormal blood glucose values. Some of us would treat him with a very small dose of insulin, perhaps a few units of either Levemir or Lantus insulin to try to save this residual beta cell pancreas function. Over the coming weeks or months, with the positive antibodies, it is likely that his beta cells will “give out” and then there will be more hyperglycemic events. The enuresis suggests that he likely has high glucose bursts periodically, perhaps for a few hours after food or snacks and then his pancreas makes a bit of insulin that brings these values back downward. Doing a series of before and after meal blood glucose levels would verify if this were the case. Sometimes in such very early diabetes patients, just a few units of Humalog or NovoLog before meals is all the insulin that is needed instead of the Lantus of Levemir previously suggested. The key is doing lots of blood glucose testing so that one does not have to guess and staying in close contact with your diabetes team to make less guesswork. Following his A1c would also let you know approximately how much time is occurring in the high versus the okay blood glucose ranges over the previous few weeks and then following this sequentially.
SB
