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November 22, 2002

Diagnosis and Symptoms

Question from Toronto, Ontario, Canada:

My 12 year old Caucasian son, who has had long history of bedwetting being a little overweight(about 27 BMI), was diagnosed with type 1A diabetes 14 weeks ago, At the time of diagnosis, his blood sugar with 600 mg/dl [33.3 mmol/L], and he had classic symptoms of thirst and excessive urination, but no DKA [diabetic ketoacidosis]. At the time of the diagnosis, it took us a three days to convince our doctor to do islet cell antibody test. He was refusing to do the test because he said my son statistically matches only type 1A, and there is no room for other diagnosis. However, three weeks ago, and it is negative.

Since first week after diagnosis, his sugar level has been within the range. so we have slowly reduced his insulin doses, and, after a month, he did not require insulin at all, but we continue to inject a one unit of short acting and one unit of long lasting insulin at the morning to avoid potential complications with introducing insulin again in the future. Until today his blood sugar is very stable, fasting glucose is never more then 11 0 mg/dl [mmol/L], he never spikes more then 160 mg/dl [mmol/L] during the day, even shortly after the meal.

During our last visit, I have asked the doctor to do a C-Peptide, but he refused, saying, “there is no need for this”. When I have asked him if there is a possibility of type 1B, MODY, or type 2 in my sons case, he said does not see such a possibility, my son has Type 1A, and time will prove it. Do you think I should look for the second opinion? Does term honeymoon apply in my son case?


From: DTeam Staff

Certainly your son’s story is somewhat unusual. If the antibody testing really was negative that would rule out type 1A (autoimmune) diabetes, but it is possible that the test was the simple ICA fluorescent screening test which can give erroneous results or that it involved only one of the now more traditional three antibody test for anti-GAD 65, anti-insulin, and ICA512/IAA. In the latter instance, only one or two of the antibodies may be detected. If the test did indeed include all three antibodies then the most probable diagnosis would be type 1B or idiopathic diabetes. This is uncommon in Caucasian children, less than 5% of new onset cases, but it would fit with the acute insulin dependent onset, the negative antibody test and the rather rapid ability to dispense with insulin. The exact cause of this type of diabetes is not known, although most of those who can manage without insulin in the near term seem to be insulin deficient and may later need supplementation again.

A BMI of 27 is high for a 12 year old boy, but an acute insulin requiring onset of type 1 diabetes would be very unusual unless there was some accompanying intercurrent infection. A serum C-peptide level that was normal or high would nonetheless be a useful indication of this increasingly common form of diabetes in the young. Likewise, with no family history, I think that one of the many varieties of Maturity Onset Diabetes of the Young MODY would be an improbable diagnosis.

Having said all this, I think it important to stress that the management of diabetes at this stage is very much the same irrespective of the particular subtype. If the final decision on the antibody tests shows them to be negative, you would certainly be able to consider dispensing with the insulin and using oral hypoglycemic agents like [metformin] to control the blood sugar, and at the same time paying some attention to achieving a more normal BMI.