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July 5, 2002

Diagnosis and Symptoms

Question from a physician in Iran:

I have a nine month old baby boy has been suffering from polydipsia and polyuria for three days, and had a blood sugar of 790 mg/dl [43.9 mmol/L]. He is being treated with insulin, but we can't quite control it. His parents are physicians, there is no family history of IDDM, he has no symptoms of a viral infection. Do you see any nine month old patients with IDDM? Is it possible? What can cause this kind of disease? If we control this with insulin, will he have any retinopathy and nephropathy?

Answer:

I think that your nine month old patient with IDDM almost certainly has type 1A (autoimmune) diabetes. There are other quite rare possibilities; but diagnosing them doesn’t really make much difference to management. This form of diabetes is uncommon, but not unknown, at this early age. It is caused, first of all, by a genetic predisposition characterised primarily by certain cell surface (HLA) proteins and then triggered by a number of environmental factors. These latter are not well understood, but there have been proponents for alpha1 beta casein in cow’s milk, enteric bovine insulin and enterovirus infections, vitamin D restriction and of course maternal rubella.

It would be important to confirm the type 1A diagnosis, if you can, by doing antibody testing — preferably the conventional triad of anti-insulin, GAD 65, and ICA 512/IA2 antibodies, but even the immunofluorscent ICA would be valuable. The reason for this is not that it would help management, but that it might suggest that it would be worth looking for evidence of other immune disorders, especially hypothyroidism Autoimmune Polyglandular Syndrome Type II. Also, it would be relevant when the time comes that transplantation with some kind of surrogate insulin producing cell together with the ability to produce graft tolerance with minimal immunosuppression becomes available.

Retinopathy and nephropathy do occur, but promise to be indefinitely contained with meticulous control of blood sugar as evidenced by the DCCT.

DOB