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January 29, 2009

Diagnosis and Symptoms

Question from Plano, Texas, USA:

My son was diagnosed with type 1 in August 2007, just after he turned five. Leading up to the diagnosis, we noticed that he was eating more, drinking more, and urinating more, but not gaining any weight. We didn't realize those were symptoms of diabetes. That was about six months before diagnosis. One morning, he was vomiting and just not himself, and had a very strong sweet smelling odor in his mouth. I took him to the doctor who tested his sugar and his urine ketones. His blood sugar was 324 mg/dl [18 mmol/L] and urine ketones were 1000. We were sent directly to hospital and he was given Lantus, maybe four units. After that initial dose, his sugar dropped to 180 mg/dl [10.0 mmol/L] and, after another dose that evening, it was back to normal, 90 mg/dl [5.0 mmol/L] to 100 mg/dl [5.6 mmol/L]. After the weekend in the hospital and going home on Lantus, he only had to have two injections at home (reduced to two units) before becoming hypoglycemic. The doctor recommended stopping the Lantus. After a year and a half, we haven't had an abnormal reading since! In fact, we've had more episodes of hypoglycemia than anything. Our endocrinologist said that he's possibly still honeymooning and that if he truly does have type 1, it will surely rear it's ugly head during puberty, which is still at least five or six years away! Can the honeymoon really last that long or could our son not really have diabetes?

Answer:

This is a very unusual medical story. Often this scenario occurs in older teenagers and young adults with a slow onset of type 1 diabetes. It would be important to know if he really has absolutely normal blood glucose levels or just approximately normal values. For instance, we would have you do a profile of blood glucose levels before breakfast and then one hour post breakfast, before lunch and one hour post lunch, before dinner and one hour post dinner. This would give you some key information about how much insulin is available, at least in relative terms on his current meal plan/diet. Similarly, if he were off insulin, I would assume that his A1c would be entirely normal, someplace around 5%. If nearer to 6%, then there are at least some intermittent episodes of hyperglycemia driving the A1c upwards. Lastly, islet cell, insulin and GAD-65 antibodies, as well as the newer Zn8 antibodies, all may be positive with type 1 autoimmune diabetes. The higher the titers and the more these antibody tests are abnormal and persistent, the more likely that the pancreas will ultimately fail. You should discuss these important questions with your diabetes team so that appropriate monitoring and follow up can occur.

SB