August 22, 2001
Diagnosis and Symptoms
Question from Albuquerque, New Mexico, USA:
My 21 month old son recently developed diarrhea and a severe ear infection during which he lost two pounds in a few weeks. Given that my wife has had type 1 diabetes for 22 years, the fact that two siblings have autoimmune diseases, and we have a nephew with diabetes, she checked his midday blood sugar which was 147 mg/dl [8.2 mmol/L] on her meter.
Several days later (with the ear infection mostly cleared), a spot check revealed a level of 247 mg/dl [13.7 mmol/L]; about 45 minutes later, it was 223 mg/dl [12.4 mmol/L], and then his sugars came down over the next hour.
Since that time, we have been instructed to test him once a day at random times. He has had overnight fasting sugars between 80-108 mg/dl [4.4-6 mmol/L]. Random checks throughout the day have mostly been around 115 mg/dl [6.4 mmol/L], but we have also had occasional readings between 140 and 150 mg/dl [7.8 and 8.3 mmol/L]. He eats continuously, so it is hard to get a clean two hour sugar.
We have recently had an extensive blood workup done, as described below: Insulin antibodies were negative. Islet cell antibodies were also negative. Islet cell AG 512 AB = 0.009 (index 0.07 as positive); GAD-65 = 0.2 U/ml. Celiac Disease antibody tests were as follows: Reticulin AB, IGA — negative; Anti-Reticulin AB, titer <10, negative. Transglutaminase IGA AB = 5, negative; Gliandin AB, IGA = 5, negative; Gliandin AB, IGG = 35, strong positive; His hemoglobin A1C was 5.1%. Given this profile, both his pediatrician and the pediatric endocrinologist have told us he was fine, unless he has more blood sugars above 200 mg/dl [11.1 mmol/L]. Nevertheless, given the family history and the one strong positive for Gliadin AB IGG, we are still concerned.
With such a formidable family history of autoimmune disorders, I can understand both your own anxiety for your son and his doctors’ meticulous investigation for the Autoimmune Polyglandular Syndrome (APS). At the same time, I quite agree that with all three antibodies for diabetes negative, that the occasional aberrant random blood sugars could well have been due to the joint stress of an illness and the sudden family enthusiasm for finger sticks. Just the same I would continue to try to get some early morning fasting blood sugars for a little while.
With the diarrhoea and the loss of weight, it is more difficult to dismiss the possibility of celiac syndrome. However, because the strongly positive IGG anti-gliadin stands out so starkly against the negative transglutaminase, I would first ask to have the former test repeated, and at the same time, you might discuss the possibility of getting an anti-21hydroxylase. This would be the next most probable disorder on the APS list.
If your small son fails to gain weight normally, if the repeat IGG is again positive or if he has another episode of diarrhoea, then I think you are going to have to face the possibility of a trial of a gluten-free diet. I have to say though that because he is still so young I would not think it necessary to insist on a small bowel biopsy first.