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August 31, 2003

Diagnosis and Symptoms, Research: Causes and Prevention

Question from Spiceland, Indiana, USA:

My 10 year old daughter, diagnosed with type 2 diabetes about a month ago, also has ocular myasthenia gravis and was being treated with prednisone. After the neurologist detected a blood glucose of 850 mg/dl [47.2 mmol/L], she was admitted into the hospital for diabetes education. She was only on insulin for two weeks until her blood glucose was under control. She currently takes 500 mg of metformin twice per day with excellent results and 5 mg of prednisone every other day for the myasthenia. She is 5 feet 2 inches tall and weighs 115 pounds, so she is not overweight, and she is involved in many outside activities. The doctor does not think that the prednisone is the culprit. He believes that the prednisone may have brought the problem to our attention a little sooner than we may have found out. I guess I am confused by all of this. She is a young girl who is active and not overweight, but is being treated for a disease that doesn't seem to fit her. What are some other causes of type 2 diabetes? Could she be resistant to her own insulin? I have these questions, and then I tend to forget everything I want to ask when I see the doctor.

Answer:

Juvenile ocular myasthenia gravis is now thought to be an autoimmune condition albeit not one that is common enough to be included with the other components of the Autoimmune Polyglandular Syndrome , the most important constituents of which are type�1A diabetes, hypothyroidism, and the celiac syndrome. This link does seem to make it more probable though that your daughter really has type 1A diabetes and not a rather atypical form of type�2 diabetes.

This diagnosis could be confirmed by appropriate antibody testing, which does however need to be done by a qualified laboratory like Quest diagnostics and also needs to include all three of the customary tests namely for anti-GAD, ICA 512, and anti-insulin antibodies. If all of this has not been done I think it should be repeated. Cortisone (a steroid) is conventional treatment for the eye disorder and would of course stress the insulin-producing islet cells to induce insulin dependency in a child in whom the diabetic autoimmune process had already been established for a number of years.

The fact that blood sugars can at present be controlled by metformin alone may simply indicate the your daughter is in what is called the honeymoon and will in the near future begin to require insulin again. Insulin resistant forms of diabetes are an unlikely possibility and could be simply tested for by measuring a fasting serum insulin level which would be normal or a little high.

Although the aim of treatment in all forms of childhood diabetes is to control blood sugars as well as possible a more precise diagnosis is important as it might indicate the need to look for yet other immune problems especially hypothyroidism and perhaps doing an anti-glutamyl transferase antibody test for asymptomatic celiac syndrome.

DOB