Interesting Diabetes Patient?

[UNMC2006]

I saw an intersting patient last week, I wanted to get some of your feedback.
A 37 year old female came in, very thin (130 lb) for a yearly physical. She had no major complaints, but did say that she had been feeling a little "odd" as of late. Nothing big, drinking a lot of water and thirsty all the time. She said that she was tired often. Thinking perhaps thyroid problems, we ordered CBC/diff, CHEM 7, and a UA. Ironically, everything was fine, but her blood sugar 256. WEIRD, no family history of diabetes, obesity, etc... Fasting sugars the next day revealed no change, 275 I think. Next step, diagnosis of type, so we took auto-insulin antibodies, negative. My preceptor calls this type 1.5 diabetes, I have never seen anything like it. Granted, my medical experience is short-lived so far, but I was wondering if some more experienced individuals could shed some light on the subject. If you need more info let me know, I have the SOAP dictated, because I was going to do some research on it. With my neuro final rolling around, I never got around to it.

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[md_student10021]

There is no such thing as type 1.5 diabetes. Perhaps your preceptor should explain things to you.

p.s. 130 lbs is not very thin, unless the woman is 6 feet tall. Even moderate amounts of abdominal adiposity can adversely affect insulin sensitivity, especially in the genetically-predisposed.

 

[tunica]

The type of diabetes could be gleaned straight from the history. She is almost assuredly a type II diabetic (support with a positive family history would be nice, but undiagnosed does not mean non-existent), unless she has some history of chronic pancreatitis or some other pancreatic insult. I have never heard of type 1.5. Perhaps that is some strange term that endocrinologists use? Don't know, but I never heard of it when I rotated on endocrinology. Her presentation is fairly standard for a patient who presents with type II diabetes (type I usually presents much earlier, and often with frank ketoacidosis). Remember this case for the boards, because it is classical. Hope you guys also remembered to do a lipid panel for her, check a HgbA1C level, check for signs or symptoms of peripheral or autonomic neuropathy, do a good check for foot ulcers, and refer her to an opthalmologist. I assume her UA was clear of protein, so her kidneys are probably alright. However, you could still check for microalbumin in the urine. You'll probably want to start her on metformin, or one of the sulfonylureas, and appropriate Rx for any lipid abnormalities or hypertension that may exist. Type 1.5 must be a joke?

 

[Brewster]

There is no such thing as Type 1.5 diabetes.

The distinction between type I and type II diabetes is not as neat as we would all like it to be...rather, the two types exist on a continuum. Some people are predominantly type I, others are predominantly type II, some (such as your patient, perhaps) are in the middle. I suspect your preceptor was not saying "This patient has type 1.5 diabetes...go look it up" but rather trying to make the point that she appears to be in the middle, with features of both type I and type II.

 

[UNMC2006]

The continum is exactly what he was referring to, I wasn't meaning to imply I think there is type 1.5 diabetics. Thanks for all your input though. She was negative for peripheal and autonomic neuropathy, lipid profile looked good as did all other blood work, as far as I know. I go back today, so maybe the picture will be complete. Thanks for you input though

 

[kcrd]

Type 1.5 refers to slow onset type I DM:

http://www.diabetesnet.com/diabetes_types/diabetes_type_15.php

 

[enamine]

I can't believe you're an actual medical student.

 

[kcrd]

I'm sorry - could you please elaborate?

 

[kcrd]

Here is another reference:

Autoimmune markers in slow type 1 diabetes: confrontation to type 1 diabetes.
Desailloud R - Diabetes Metab - 01-Nov-2000; 26(5): 353-60
From NIH/NLM MEDLINE


NLM Citation ID:
11119014 (PubMed}
20569040 (MEDLINE)


Author Affiliation:
Service d'Endocrinologie et de Diab?tologie, Clinique Marc Linquette, Centre Hospitalier R?gional et Universitaire de Lille.

Authors:
Desailloud R; Fajardy I; Vambergue A; Prevost G; Pigny P; Fontaine P

Abstract:
Slow onset type 1 diabetes is an heterogeneous entity. Its clinical features may mimick type 2 diabetes but its pathophysiological mechanisms are close to type 1 diabetes. AIM OF THE STUDY: To find out the frequencies, levels and associations of ICA, GADab and IA-2ab in type 2 diabetic patients with atypical phenotype. To compare it to type 1 diabetes. PATIENTS AND METHODS: ICA, GADab and IA-2ab were determined in: - 61 patients (age at diagnosis 48.2 +/- 10, range 36-73 years) with an initial diagnosis of type 2 diabetes but having at least one symptom suggesting a slow type 1 diabetes (loss of weight, absence of obesity at diagnosis or secondary failure of oral hypoglycaemic agents). - 70 patients with type 1 diabetes (age 18 +/- 8.9, range 2-35 years). Clinical data evaluated in slow type 1 were maximal BMI, BMI and loss of weight at diagnosis and autoimmune disease. Fasting C-peptide and insulinemia were also assessed. RESULTS: (Slow type 1 diabetes versus type 1 diabetes). ICA (43% vs 70%; p <0.01) and IA-2ab (16% vs 75%; p <0.01) were more frequent in type 1. GADab were as frequent (62% vs 74%). Association of the three antibodies (15.7% vs 58.5%; p <0.05) were more frequent in type 1. Prevalence of GADab alone (27.5% vs 7.5%; p <0.05) was higher in slow type 1 diabetes and with higher levels (median 55.5 UI/ml vs 17 UI/ml; p <0.01). There was no difference for levels of ICA (25.5 UJDF/ml vs 28 UJDF/ml) or IA-2ab (11.5 UI/ml vs 38.5 UI/ml). BMI of GADab positive patients was lower. Delay of insulinotherapy was shorter in GADab or ICA positive patients. We did not find any relationship between antibodies presence and fasting C-peptide or insulinemia. CONCLUSION: Slow type 1 diabetes should be evoked in atypical type 2 diabetes. Slow onset type 1 diabetic patients have different autoimmune patterns suggesting a different pathophysiological process. GADab and ICA are useful markers to predict future insulinopenia.

 

[southerndoc]

Originally posted by UNMC2006
she had been feeling a little "odd" as of late. Nothing big, drinking a lot of water and thirsty all the time. She said that she was tired often. Thinking perhaps thyroid problems, we ordered CBC/diff, CHEM 7, and a UA. Ironically, everything was fine, but her blood sugar 256. WEIRD, no family history of diabetes, obesity, etc... Fasting sugars the next day revealed no change, 275 I think.

She has tiredness and polydipsia, and you think thyroid problems? Hmm.

My first thought would be diabetes. I'd bet she also probably had polyuria, nocturia, and quite possibly blurred vision (especially after eating).

Although it's unlikely, do keep in mind the possibility of dietary habits causing hyperglycemia. I wouldn't expect this in her (since her BS is so high), but I once saw a pediatric patient who had a blood sugar of 200. Turns out she was drinking and eating God awful amounts of sugar. Reduced her sugar intact, and voila, back to normal she was. Oh, her fasting BS? Evidently she didn't understand that when one says "don't eat or drink anything" that it also applies to Coca-Cola and orange juice.

 

[UNMC2006]

Thanks guys! I have been trying to sort out diabetic diagnosis for awhile. Being an M1, things are still a little hazy, still seeing everything in terms of answers A-E, for another few days or so. This was an interesting case turns out, I didn't get to follow up because it was over, but I asked my preceptor how it went out of curiosity, and like any busy doc, he forgot, so I got the chart. His final diagnosis was slowly progressive Type I diabetes. Not a shock to you experienced clinical posters out there, and to me no longer. Thanks for your help.