May 31, 2005
Diagnosis and Symptoms
Question from Amarillo, Texas, USA:
Our now five year old daughter was diagnosed with type 1 in November of 2004. Although her random glucose tests had been normal (we were monitoring her because of constant, soaking bed wetting), her fasting insulin level was low. It was less than two per one lab and just at two per another, with a fasting glucose of 74 mg/dl [4.1 mmol/L] with the less than two reading. We had her tested for autoantibodies, which were negative at the time, but she still had an estimated 50 to 60% of her pancreatic function left.
This may sound like overkill for bed wetting, but I, her mother, have had type 1 for 20 years, and was seeing the same symptoms I originally presented with, although it took six years from the onset of my pathological bed wetting to the eventual diagnosis due to full blown DKA. We had one reading on her as high as 186 mg/dl [4.8 mmol/L] post-prandial and some post prandial readings in the 130s mg/dl [7.2 to 7.7 mmol/L]. Looking back, that higher number might have been due to a contaminant on her finger. She is currently on Lantus 1/2 unit per day.
Prior to starting the Lantus, she was not gaining weight and was beginning to look gaunt. Her normally full cheeks had taken on a slightly sunken appearance and her eyes had very dark circles under them. She was showing some signs of dehydration, slow cap refill and just looking a little dry. Every now and then, she would show small ketones, despite normal blood sugars for the entire day and night. We were testing frequently to try and figure out if she was spiking somewhere. Her laboratory tests were relatively normal, but in light of the above information, and the fact that she looked so bad, they started her on that slight dose of Lantus. Her blood sugars have been picture perfect since then, and even on a day when we did not give her shot, they were normal.
Does this sound like a very early type 1? I wonder if the insulin is necessary, but after we started it, she began to look much better and has had more dry nights (which never happened before). I guess I just wonder if there might be something else that we missed, or if this is truly type 1. Although she looks much better, fuller cheeks, weight gain, etc., is this enough, coupled with the low insulin level and family history, to truly diagnose type 1?
Answer:
This is an unusual story, but could be a very early example of type 1 diabetes with enough insulin deficiency to cause some intermittent hyperglycemia and enuresis. There is some research that suggests that a small dose of insulin, such as the small amount of Lantus that you are using, saves the damaged pancreas from overworking and reduces the glucose toxicity and further beta cell damage. I would go back and ask these questions to your pediatric diabetes team since they have all of the relevant tests available and could give you the best answers. Time will really tell you whether this diagnosis is correct or not since every child this age eventually needs a higher dose of insulin than what you describe. Antibody testing is only helpful about 50 to 60% of the time, but sequential testing would also be a possible help as might C-peptide levels.
SB
