A 16-year-old girl went to her pediatrician for her annual visit and complained that she was very tired for a while. Nevertheless, she just finished the 10th grade with minimal absences.
She has a history of obesity and weighs as much as 230 pounds on a 5-foot-3 frame. But last year she devoted herself to improved nutrition and exercise. She stopped drinking sweetened sodas in favor of lots of water.
Her parents agree that her diet was healthier, but her exercise was minimal.
Both the pediatrician and the family were happy to learn that in the last six months, their weight dropped to 205 pounds. But she can not understand why she is so tired despite her healthier lifestyle.
Fatigue is one of the most difficult symptoms to be resolved because it is found in so many teens.
Some reports indicate that 40 percent of healthy teenagers experience regular drowsiness and 30 percent fatigue (low energy perception after normal activity). Causes can be infections (eg mononucleosis), anemia (low red blood cells), hypothyroidism, sleep disorders and depression.
In this case, the pediatrician asked her many questions. She denied fever or sore throat (mono), sleep disturbances (obstructive sleep apnea), bleeding like strong periods (which could lead to anemia), and she denied a history of depression. The girl's mother reported being diagnosed with hypothyroidism in her 20s. Hypothyroid symptoms can be fatigue and drowsiness, weight gain, dry skin, constipation, irregular menstrual cycles, feeling cold and an enlarged thyroid gland. But the girl said she has none of these symptoms except fatigue and some drowsiness.
She said that her only sleep problem was getting up at night to urinate ̵
Examine them, the doctor noticed that the skin behind her neck was dark. Her mother said she had tried several times to scrub, but to no avail. The doctor recognized the condition as acanthosis nigricans, a skin disease with insulin resistance and type 2 diabetes. He also discovered that a rash in her groin was a fungal infection, a condition that thrives in moist areas of the body, especially when blood sugar is elevated.
The doctor ordered blood tests. She had no anemia and thyroid function was normal. Her non-fasting blood glucose was 190 mg / dL and hemoglobin A1c 6.4%. She was on the line: A blood sugar level above 200 mg / dL with symptoms would establish a diagnosis of diabetes mellitus. For example, a reading above 6.4 would be based on their hemoglobin A1c, a blood test that correlates to average blood glucose levels in the last two to three months.
She was sent to a pediatric endocrinologist six weeks later with the diagnosis of prediabetes. Acanthosis nigricans, yeast infection and obesity. This time her blood glucose reading was 314 mg / dL and hemoglobin A1c was 7 percent.
The pediatric endocrinologist learned that a grandmother was recently diagnosed with type 2 diabetes.
Did this teen have Type 2 diabetes?
The diagnosis is clearly diabetes mellitus in a child with insulin resistance and obesity. Type 2 diabetes typically occurs over months and usually does not require urgent treatment, which appears to be the case with this patient.
But the endocrinologist did not stop it. Since the girl's mother is suffering from hypothyroidism (Hashimoto's thyroiditis), autoimmune disease has increased the likelihood that the girl actually has Type 1 diabetes, including an autoimmune disease.
When a child – especially an overweight teenager – presents a new onset diabetes, it can be difficult to decide immediately what kind of diabetes exists. If a child is under 6 years old or very thin, type 1 diabetes is likely. If a child is seriously ill and has "diabetic ketoacidosis," Type 1 is likely.
When a child is in puberty, like this patient, insulin needs are greater, which explains why type 2 diabetes can develop Children whose insulin needs are also increased due to factors such as obesity and heredity.
Type 2 diabetes is more common among blacks, Hispanics, and Native Americans. A family history of diabetes is more common with type 2 than with type 1.
The girl was started on insulin. A week later, a blood test – the autoimmune diabetes panel – showed elevated diabetes antibodies.
So she actually had Type 1 diabetes. Acanthosis nigricans indicates that their insulin levels were previously elevated, indicating a risk for both types of diabetes.
This case shows that despite the obesity epidemic, which increases the risk of type 2 diabetes in children, an overweight child must be considered with pre-diabetes (increased glucose, but not entirely in the diabetic area), type Have -1 diabetes.
This is very important because the Type 1 body destroys its own insulin-producing beta cells. Type 2, however, is a metabolic disorder, not an autoimmune disease. Type 2 develops insulin resistance. So, if this girl had been treated for type 2, she probably would not have been given aggressive insulin therapy and was at risk for a condition called diabetic ketoacidosis (DKA). DKA is a condition that can be fatal but is rarely seen in type 2 diabetes.
Craig A. Alter, MD, is a pediatric endocrinologist and director of the Pituitary Center in the Department of Endocrinology and Diabetes at Children's Hospital of Philadelphia