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March 18, 2006

Diagnosis and Symptoms

Question from Paola, Kansas, USA:

In October 2005, my three year old daughter was diagnosed with a seizure disorder that is thought to be autoimmune in origin. She has been in the hospital several times since then and has undergone a lot. She had random elevated blood sugars back in January of 2206 during her hospital stay, but they were dismissed and thought to be related to her other issues. Shortly after discharge, she began to become very thirsty, was up several times a night to go to the bathroom, and was eating nonstop. She had not gained any weight, and, in fact, lost some over the last several months. I expressed my concern about her symptoms so an A1c was run, which came back normal, 4.0. Her symptoms however persisted. During an overnight stay at the hospital for an EEG, a random finger stick showed a fasting of 176 mg/dl [9.8 mmol/L]. We then saw an endocrinologist who ran blood work. Again, her A1c was normal, as was her fasting blood sugar that day. She tested negative for ICA, and the insulin antibody, but was positive for GAD, 2.3 (range was less than 1.0). Her blood sugars fluctuate daily. She has had sugars in the 200s mg/dl [over 11.1 mmol/L] after meals, and had a fasting at home of 149 mg/dl [8.3 mmol/L]. These are not consistent. Her symptoms seemed to have decreased somewhat, but she is wetting her pants now unlike before when she wasn't. We did a CGM at the hospital and she was within range on almost all tests. It did show that she does tend to rise after a meal. Does all of this sound like a type 1 diagnosis? Could there be any other cause for a positive GAD? Is it normal for sugars to fluctuate early on or is this not diabetes? Was the A1c test run too early to show anything (only about five weeks after onset of symptoms)? For now, we were told just to check her sugars periodically, and see doctor this summer. Also, a meal for her is not very much. As she gets older and her meals become larger quantities, will we have a better indication of her true sugars?


Without seeing the actual blood glucose levels, it is difficult to comment with any specificity. This sounds like it could be the early onset of type 1 diabetes with a positive GAD antibody despite negative islet cell antibody. This is not uncommon, especially in very young children. I suspect this is not related to her seizure disorder at all although some other medications occasionally can cause glucose intolerance.

In general, without persistent glucose abnormalities, we would usually recommend close blood glucose monitoring and attention to symptoms (changes in urination, thirst, weight, etc.), as you are doing, and starting insulin treatment, if and when there are more persistent abnormalities of the actual blood glucose readings themselves. The A1c only reflects average glucose readings for the previous four to six weeks, so the normal values merely state what you already know from more detailed blood glucose monitoring, that there is not persistent hyperglycemia. I also would suggest staying in close contact with the pediatric diabetes team since they can give you more specific advice.