A case of type 1.5 diabetes mellitus or LATENT AUTOIMMUNE DIABETES IN ADULT 3RD MEDICAL UNIT CHIEF PROF Dr. M. NATARAJAN MD ASST Dr. SYED BAHAVUDEEN HUSSAINI MD DNB ASST Dr. VALLIDEVI MD ASST Dr.SHANMUGANATHAN MD Presentor- YAGNESHWARARAJA

A 30 years old female came with presenting C/O polyuria for 2months polydypsia for 2months

History Of Presenting Illness H/O Polyuria for 2months- >4litres /day. H/O Polydypsia for 2months H/O weight loss around 3-4 kgs No H/O Burning Micturition No H/O Polyphagia No H/O Fever No h/o abdominal pain No h/o genital itching

No H/O Chestpain/ Palpitation/ Breathlessness No H/O Cough with expectoration No H/O Blurring of vision No H/O Drug intake No H/O Trauma to head

PAST HISTORY FAMILY HISTORY no family h/o diabetes mellitus . Not a known case of DM/SHTN No H/O PTB/CAD/Thyroid disease/Seizures. FAMILY HISTORY no family h/o diabetes mellitus . PERSONAL HISTORY Mixed diet Normal bowel habbits.

MENSTRUAL HISTORY Unmarried Regular cycles 3/30 LMP- 30/06/2017

GENERAL EXAMINATION Consious, Oriented, Afebrile, No Pallor, No Icterus, No Cyanosis, No Pedal Edema, No Generalized lymphadenopathy

Markers of insulin resistance like acanthosis nigricans, skin tags are absent Her BMI is 23.16(Wt-60 kgs,Ht-161 cms) normal body mass index stigmata for autoimmune illness such as vitilligo,goitre,arthralgia are ABSENT

VITALS PULSE RATE -82/min Regular BLOOD PRESSURE - 120/70mm Hg RESPIRATORY RATE - 18/min SpO2 -97% at room air

SYSTEMIC EXAMINATION CVS –S1 S2 +, no murmur, RS-BAE +, no added sounds, P/A-SOFT, no organomegaly, CNS-NO FND, FUNDUS-normal,no e/o diabetic retinopathy or optic atrophy.

INVESTIGATION Hb- 13.3gms/dl RBC- 5.13 million/cu.mm. TC- 8300 DC- Neutrophils- 62.1%, Lymphocytes-31.6%, Eosinophil-2.2%, Monocytes-3.7%, Basophil -0.4% ESR(Auto)- 30mm/hr.

PCV- 42.9% MCV- 83.7 MCH – 25.9 MCHC-30.9 PLATELET COUNT- 2,49,000 cells/cumm. RDW- 14.7 ABSOLUTE EOSINOPHIL COUNT- 200 RETICULOCYTE COUNT- 0.70

RBS- 530 mg/dl FBS- 234 mgs/dl PPBS- 427mgs/dl UREA- 17 mgs/dl CREATININE- 0.86mgs/dl

FASTING LIPID PROFILE: Total Cholestrol- 196mg/dl HDL - 38mg/dl LDL -135mg/dl VLDL -30mg/dl TGL -149mg/dl

Sr. Uric acid – 2.9 mg/dl THYROID PROFILE : FT4- 1.14ng/dl(0.89-1.72) TSH- 1.81mIU/L(0.4-4.50) HbA1C- 12.94% Sr. FASTING C-PEPTIDE- 0.67ng/ml (ref range- 0.8-3.1ng/ml)-after achieving glycaemic control.

URINE ALBUMIN- NIL GLUCOSE(F)- ++ DEPOSIT - 1-2 Occasional pus cells/hpf. Epi cells + No RBC/CAST/CRYSTALS. ACETONE - positive

USG- ABD AND PELVIS UTERUS- Normal size, Anteverted Normal Endometrial thickness. LT OVARY- Dominant Follicle RT OVARY- Small Cystic lesion(1.6*1.4*2cm) with dense echogenic content suggestive of early dermoid. Fluid filled segment of Ascending colon and Caecum upto Hepatic Flexure- Non specific segmental colitis.

LIVER/GB/PANCREAS/KIDNEYS/SPLEEN/BL ADDER- NORMAL No E/O Free fluid in peritoneum Rpt USG after 1month to reassess size and morphology of cyst.

IMMUNOLOGY SERUM ANTI GAD ANTIBODIES 106.3 IU/ml.(Increased) (<30: neg, >30: pos) This assay is a tool in the diagnosis of type 1 DM.

TREATMENT She was started on insulin infusion. Responded well, controlled sugar levels. Now converted into subcutaneous insulin. Sugar levels are under control.

DISCUSSION WITH DIABETOLOGIST To differentiate LADA and DIDMOAD it will be useful to 1)assess urine specific gravity,urine osmolality after achieving glycaemic control 2)audiometry-if required Fasting C-peptide-can be correlated with corresponding FBS Subclinical preceding viral infection could have been initiated the process

SUMMARY 30 yrs old female patient 1)with h/o polyuria,polydypsia weight loss, 2)with negative family h/o, 3)normal BMI, 4)without any markers for insulin resistance or autoimmune illness, NO e/o diabetic retinopathy or optic atrophy 5)with elevated sugar values,high Hb A1c 6)low fasting C-peptide levels 7)acetone positive 8)anti GAD positivity,responded well to insulin infusion,now on subcutaneous insulin

AIM OF PRESENTATION Approach towards diabetes mellitus in third decade TYPE 1 DM TYPE 1.5 DM MODY TYPE 2 DM