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New-onset diabetes in an obese adolescent: diagnostic dilemmas

Nature Clinical Practice Endocrinology & Metabolism volume 4, pages 578–583 (2008)Cite this article

Abstract

Background A 14-year-old, obese, African American boy presented to his pediatrician with polyuria, polydipsia, and a significant unintentional weight loss. He was dehydrated, with high levels of blood sugar and urinary ketones. He had no history of previous illnesses and was not taking any medications. He had a family history of type 2 diabetes mellitus.

Investigations Physical examination included assessing stigmata of insulin resistance, and measuring blood pressure, pulse, and BMI. Blood samples were obtained for measurement of venous blood pH, bicarbonate, serum glucose, electrolytes, HbA1C, aminotransferases and lipids. Urine was sampled for measurement of ketones. Subsequently, measurements of fasting C-peptide and immunoassays for insulin autoantibodies (IAA), islet-cell autoantibodies (ICA-512) and glutamic acid decarboxylase autoantibodies (GAD-65) were performed.

Diagnosis New-onset diabetes mellitus with diabetic ketoacidosis, initially diagnosed as type 2 diabetes mellitus, but later determined as type 1 diabetes mellitus.

Management After treatment of diabetic ketoacidosis with hydration and insulin infusion, the patient was discharged on subcutaneous insulin. He was diagnosed with type 2 diabetes mellitus and was transferred to oral insulin-sensitizing agents. He re-presented 18 months later with an insulin requirement during an asthma exacerbation treated with steroids. Due to the worsening of his diabetic symptoms, the patient was tested for islet autoantibodies and was found to be positive for GAD-65 and IAA, that is, diagnostic of type 1 diabetes mellitus. He has continued to require subcutaneous insulin.

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Figure 1: BMI distribution showing a significant number of antibody-negative cases in the lean population and antibody-positive cases in the obese population.
Figure 2: Antibody positivity and number of positive antibodies predict the risk for insulin requirement during 6 years after diagnosis.
Figure 3: C-peptide production declines gradually in patients with new-onset diabetes and cannot be used for diagnosis in the initial months.

References

  1. Dunger DB et al. (2004) European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 113: e133–e140

    Article  Google Scholar 

  2. Wang J et al. (2007) Prevalence of autoantibody-negative diabetes is not rare at all ages and increases with older age and obesity. J Clin Endocrinol Metab 92: 88–92

    Article  CAS  Google Scholar 

  3. Wenzlau JM et al. (2007) The cation efflux transporter ZnT8 (Slc30A8) is a major autoantigen in human type 1 diabetes. Proc Natl Acad Sci USA 104: 17040–17045

    Article  CAS  Google Scholar 

  4. Lifshitz F (Ed.; 2007) Pediatric Endocrinology, edn 5 Vol. 1, 57–61, 63–77, 83–93, 169–183, 211–257. New York: Informa Health Care USA

    Google Scholar 

  5. Lann D and LeRoith D (2007) Insulin resistance as the underlying cause for the metabolic syndrome. Med Clin North Am 91: 1063–1077

    Article  CAS  Google Scholar 

  6. Umpierrez G et al. (2006) Narrative review: ketosis-prone type 2 diabetes mellitus. Ann Intern Med 144: 350–357

    Article  Google Scholar 

  7. Cook S et al. (2003) Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988–1994. Arch Pediatr Adolesc Med 157: 821–827

    Article  Google Scholar 

  8. American Diabetes Association (2008) Diagnosis and classification of diabetes mellitus. Diabetes Care 31: S55–S60

  9. Pinhas-Hamiel O et al. (1997) Diabetic ketoacidosis among obese African-American adolescents with NIDDM. Diabetes Care 20: 484–486

    Article  CAS  Google Scholar 

  10. Writing Group for the SEARCH for Diabetes in Youth Study Group (1997) Incidence of diabetes in youth in the United States. JAMA 297: 2716–2724

  11. Turner R et al. (1997) UKPDS 25: autoantibodies to islet cell cytoplasm and glutamic acid decarboxylase for prediction of insulin requirement in type 2 diabetes. UK Prospective Diabetes Study Group. Lancet 350: 1288–1293

    Article  CAS  Google Scholar 

  12. American Diabetes Association (2000) Type 2 diabetes in children and adolescents. Diabetes Care 23: 381–389

  13. Allen HF et al. (1999) Effect of Bacillus Calmette-Guerin vaccination on new onset type 1 diabetes. A randomized clinical study. Diabetes Care 22: 1703–1707

    Article  CAS  Google Scholar 

  14. Jones KL (2008) Role of obesity in complicating and confusing the diagnosis and treatment of diabetes in children. Pediatrics 121: 361–368

    Article  Google Scholar 

  15. Gilliam LK et al. (2005) Autoimmunity and clinical course in children with type 1, type 2, and type 1.5 diabetes. J Autoimmun 25: 244–250

    Article  CAS  Google Scholar 

  16. Silverstein J et al. (2005) Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care 28: 186–212

    Article  Google Scholar 

Download references

Acknowledgements

CM Gerhardt would like to thank her mother, Nancy, for her enthusiastic support of both career and family and the NIH Training Grant (5 T32 DK63687) by which she is financially supported.

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Authors and Affiliations

  1. CM Gerhardt is a fellow in Pediatric Endocrinology, and GJ Klingensmith is a Professor of Pediatrics and Clinical Director of Pediatric services, at the Barbara Davis Center for Childhood Diabetes at the University of Colorado, Denver, CO, USA.,

    Christina M Gerhardt & Georgeanna J Klingensmith

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  1. Christina M Gerhardt
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  2. Georgeanna J Klingensmith
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Correspondence to Christina M Gerhardt.

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Gerhardt, C., Klingensmith, G. New-onset diabetes in an obese adolescent: diagnostic dilemmas. Nat Rev Endocrinol 4, 578–583 (2008). https://doi.org/10.1038/ncpendmet0950

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