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August 18, 2007

Diagnosis and Symptoms

Question from Tucson, Arizona, USA:

My daughter was diagnosed with diabetes at age eight by complete accident. She had been running a high fever for more than 10 days. Her primary care physician did a urinalysis for a UTI and found sugar in her urine. They tested her blood sugar in the office and she was 285 mg/dl [15.8 mmol/L]. They sent us straight to the hospital with a probable diagnosis of type 1 diabetes, caught extremely early. Thin, athletic and very active, my daughter has been tested routinely for antibodies and it always comes back negative. She initially used insulin but then did not require any for over six months, possibly her honeymoon. The doctor put her on metformin. He said that she didn't fit a type 1 category, but not a type 2 category either. Over the next year, she became insulin dependent and now uses an insulin pump with Humalog. She still takes the metformin. She rarely has anything above trace ketones when sick or above target. In addition, she was diagnosed this year with Hashimoto's thyroiditis, which I understand is not uncommon in type 1 diabetics. I have been frustrated with her diagnosis hanging out there..."somewhere between a type 1 and type 2" as our pediatric endocrinologist tells us. He says they don't have a label for her. I was wondering about type 1b. Is this possible? She is Caucasian and I understand this is not common with that background. Any help you can provide would be most appreciated.

Answer:

The antibody tests we have available are not 100% perfect and only detect about 60 to 80% of those with autoimmune diabetes. If she were in a research protocol, you might get other antibody levels drawn or even specific genetic testing, but it does not change much of what you are doing on a day to day basis. Why is she still on metformin if she is not obese? Most pediatric diabetologists would not stop insulin completely even in a honeymoon period since there is some evidence that even small amounts of insulin allow the damaged pancreas to “rest.” This is moot in your case since you are past this point in time. If you suspect some other type of diabetes, there are MODY tests available, but they are expensive. I would have you go back to your diabetes team and explore what is currently known, available and to what benefit anymore information might have. With thyroiditis plus type 1 diabetes, it is more likely garden variety type 1 autoimmune diabetes. Any positive transglutaminase antibody (celiac disease)? This is the next most common problem after thyroid issues.

SB