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11-28-2017 | Latent autoimmune diabetes of adulthood | Case report | Article

Latent autoimmune diabetes of adulthood: case report

Journal: Clinical Diabetes and Endocrinology

Authors: Cristen P. Page, Brian Fitzgerald, Emily M. Hawes

Publisher: BioMed Central



Primary care clinicians will see a higher incidence of type 2 diabetes in adult patients, and the diagnosis and management of an initial presentation of type 1 diabetes can pose challenges to clinicians who see it less frequently. Symptoms of hyperglycemia and risk of ketoacidosis may be missed. Further, endocrine autoimmune disease can run together in patients and families.

Case presentation

A 49-year-old Caucasian female with history of pituitary adenoma and Graves’ disease with history of thyroid ablation presented in the outpatient setting due to hand tingling of her right middle finger that was worse in the mornings and improved throughout the day. She also complained of excessive thirst, finding herself drinking more water than usual and waking up in the night to urinate. There was no dysuria or haematuria, and no other neurologic symptoms. She did report feeling hungry. She had no family history of diabetes, normal body mass index of 21.7, and reported taking her thyroid replacement medication every day. The differential diagnosis for her thirst included dehydration, psychogenic polydipsia, diabetes mellitus, diabetes insipidus, and anxiety. The patient had normal vital signs and was well appearing; labs were ordered for her on her way home from clinic with no medications. Labs revealed a random blood glucose level of 249 mg/dL, normal renal function, a normal B12 of 996 pg/mL, and an elevated thyroid stimulating hormone level of 25.67 u[iU]/mL. On follow up with her primary care provider 5 days later, additional labs were drawn showing A1C of 11.5%, 1+ ketonuria, a negative Acetest, and a normal basic metabolic panel, except for a fasting glucose of 248 mg/dL, and Free T3 of 2.42 pg/mL, and Free T4 of 1.7 ng/dL. Islet cell antibodies and glutamic acid decarboxylase antibodies were both positive, consistent with type 1 diabetes. She was started on insulin and improved.


Given the patient’s age, this is a less common presentation of type 1 diabetes mellitus, as a part of polyglandular autoimmune syndrome type IIIa. It serves as a reminder that clinicians should remember that patients with one autoimmune disease (in this case, h/o Graves’ disease) are at higher risk for diabetes and other endocrine autoimmune diseases and should be screened appropriately. Clinicians should keep latent type 1 diabetes in the differential in adulthood to ensure proper and timely treatment.
American Diabetes Association. Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes 2017. Diabetes Care 2017;40(Suppl. 1):S11–S24.
White RD, Harris GD. Case study: “birds of a feather flock together”: type 1A diabetes and other autoimmune disease states. Clin Diabetes. 2006;24(1):40–3.CrossRef
McCullough DK. Clinical presentation and diagnosis of diabetes mellitus. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed 20 September 2017.
McCullough DK. Classification of diabetes mellitus and genetic diabetic syndromes. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed 20 September 2017.
Chiang JL, Kirkman MS, Laffel LM, Peters AL. Type 1 Diabetes Sourcebook Authors. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care. 2014;37(7):2034–54.CrossRefPubMed
Kahaly GJ, Frommer L. Polyglandular autoimmune syndromes. J Endocrinol Investig 2017 . doi: https://​doi.​org/​10.​1007/​s40618-017-0740-9. [Epub ahead of print] Review.
Laugesen E, Østergaard JA, Leslie RD. Danish Diabetes Academy Workshop and Workshop Speakers. Latent autoimmune diabetes of the adult: current knowledge and uncertainty. Diabet Med. 2015;32(7):843–52. https://​doi.​org/​10.​1111/​dme.​12700. Epub 2015 Feb 7CrossRefPubMedPubMedCentral
Merger SR, Leslie RD, Boehm BO. The broad clinical phenotype of type 1 diabetes at presentation. Diabet Med. 2013;30:170–8.CrossRefPubMed
American Diabetes Association. Pharmacologic approaches to glycemic treatment. Sec. 8. In standards of medical Care in Diabetes 2017. Diabetes Care. 2017;40(Suppl. 1):S64–74.CrossRef
Masharani U. Diabetes mellitus & hypoglycemia. In: Papadakis MA, McPhee SJ, Rabow MW, editors. Current Medical Diagnosis & Treatment 2015. New York: McGraw-Hill; 2014.
Törn C, Landin-Olsson M, Ostman J, et al. Glutamic acid decarboxylase antibodies (GADA) is the most important factor for prediction of insulin therapy within 3 years in young adult diabetic patients not classified as type 1 diabetes on clinical grounds. Diabetes Metab Res Rev. 2000;16(6):442–7.CrossRefPubMed
Lexicomp Online ®, Insulin lispro: Drug information. Insulin Lispro, Lexi-Drugs®, Hudson, Ohio: Lexi-Comp, Inc.;2015. https://​online.​lexi.​com/​lco/​action/​doc/​retrieve/​docid/​fc_​dfc/​5548571. Accessed 20 Sept 2017.
Masharani U, German MS. Pancreatic hormones and diabetes mellitus. In: Gardner DG, Shoback D. editors. Greenspan’s Basic & Clinical Endocrinology, 9e. New York: McGraw-Hill; 2011. http://​accessmedicine.​mhmedical.​com/​content.​aspx?​bookid=​380§ionid=​39744057. Accessed 20 Sept 2017.
Ross DS. Diagnosis of hyperthyroidism. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed 20 Sept 2017.
Thakkar UG, Vanikar AV, Trivedi HL. Polyglandular autoimmune syndrome type III: two cases. Sri Lanka J Child Health. 2013;42:217–8.CrossRef
Hansen MP, Matheis N, Kahaly GJ. Type 1 diabetes and polyglandular autoimmune syndrome: a review. World J Diabetes. 2015;6(1):67–79.CrossRefPubMedPubMedCentral
Dittmar M, Kahaly GJ. Genetics of the autoimmune polyglandular syndrome type 3 variant. Thyroid. 2010;20(7):737–43. https://​doi.​org/​10.​1089/​thy.​2010.​1639.CrossRefPubMed
Simmons KM, Gottlieb PA, Michels AW. Immune intervention and preservation of pancreatic Beta cell function in type 1 diabetes. Curr Diab Rep. 2016;16(10):97. https://​doi.​org/​10.​1007/​s11892-016-0793-8.​ CrossRefPubMed
Thunander M, Thorgeirsson H, Törn C, Petersson C, Landin-Olsson M. β-cell function and metabolic control in latent autoimmune diabetes in adults with early insulin versus conventional treatment: a 3-year follow-up. Eur J Endocrinol. 2011;164(2):239–45. https://​doi.​org/​10.​1530/​EJE-10-0901. Epub 2010 Nov 18CrossRefPubMedPubMedCentral
Munir KM, Davis SN. The treatment of type 1 diabetes mellitus with agents approved for type 2 diabetes mellitus. Expert Opin Pharmacother. 2015;16:2331–41.CrossRefPubMed
Livingstone R, Boyle JG, Petrie JR, REMOVAL Study Team. A new perspective on metformin therapy in type 1 diabetes. Diabetologia. 2017; https://​doi.​org/​10.​1007/​s00125-017-4364-6.​
Ghazi T. Rink, Sherr JL, Herold KC. Acute metabolic effects of exenatide in patients with type 1 diabetes with and without residual insulin to oral and intravenous glucose challenges. Diabetes Care. 2014;37:210–6.CrossRefPubMed
Mottalib A, Kasetty M, Mar JY, et al. Weight Management in Patients with type 1 diabetes and obesity. Curr Diab Rep. 2017;17(10):92. https://​doi.​org/​10.​1007/​s11892-017-0918-8.​ CrossRefPubMedPubMedCentral
Perkins BA, Cherney DZ, Partridge H, et al. Sodium-glucose co transporter 2 inhibition and glycemic control in type 1 diabetes: results of an 8-week open label proof-of-concept trial. DiabetesCare. 2014;37:1480–3.

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