1. 조절되지 않는 혈당을 주소로 내원한 44 세 남자 환자 경희의료원 내분비 내과 R2. 이정훈 / prof. 우정택 1

2. 임 O 준 (M/44) 2 Chief complaint Polydipsia, Polyuria o/s) 3 weeks ago Present illness 44 세 남자환자, 2002 년부터 primary clinic 에서 DM 진단받고 불규칙적으로 OHA medication 해오던 자로 내원 3 주전부터 시작된 상기 증상과 고혈당 지속되어 이에 대한 조절 및 evaluation 위해 내원함.

3. 3 PMHx DM/HTN/TB/Hepatitis (+/-/-/-) DM : 2002 년 진단 ( 당시 36 세 ) DKA (-), HHS (-) PHx Alcohol (+) : 2~3 잔 ( 소주 ) X 1 회 /wk Smoking (-) Drug Hx Herbal medication (-) Metformin HCl 1000mg 1T bid Allergy Hx (-) OPHx (-) Metformin HCl 1000mg 1T bid 02 년 진단 당시부터 복용 불규칙적인 OHA medication (+) 용량 지속적으로 증량하여 온 상태

4. 4 FHx stroke Arrythmia Liver Cirrhosis

5. Review of System 5  General fatigue (+) febrile sense/chilling (-/-) weight change (+) : 3~4kg weight loss/ 6 month  Eye & ENT decreased visual acuity (+) tinnitus (-) hearing disturbance (-) PND (-)  Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-)  Cardiac chest discomfort (-) palpitation (-) orthopnea (-)  Gastrointestinal A/N/V/D/C (-/-/-/-/-) abd. pain (-) melena (-) hematemesis (-)  Genitourinary dysuria (-) frequency (-) flank pain (-) dysmenorrhea (-)  Endocrine heat intolerance (-) polydipsia (+) cold intolerence (-) polyuria (+)

6. Physical Examination 6 1. General Alert conciousness Not so ill looking appearance 2. Head and Neck No thyroid enlargement or tenderness No neck vein engorgement 3. Eye/ENT Isocoric pupil and PLR (++/++) Pinkish conjunctivae Whitish sclerae PI (-) PTH (-/-) 4. Thorax Clear breathing sound without rale Regular heart beat without murmur 5. Abdomen Soft & flat abdomen Normoactive bowel sound Tenderness (-) rebound tenderness (-) 6. Back / Extremity CVA tenderness (-/-) Pretibial nonpitting edema (-/-) Vital sign : 120/80 mmHg – 72 회 /min – 20 회 /min – 36.4°c Ht. : 169.3cm Wt. : 51.59kg BMI : 18.1 kg/m 2

7. Initial Lab Findings 1. CBC/DC 9190/mm² - 12.2 g/dl – 36.3% - 556K (seg. 78.9%) PT (INR) 12.5 sec (1.17%) aPTT 36.5 2. Chemistry TB 0.4 mg/dL AST/ALT 36/48 IU/L ALP/GGT 86/26IU/L Prot/Alb 6.5/4.1 g/dL BUN/Cr 24/0.4 mg/dL Na/K/Cl 132/4.6/95 mmol/L Ca/P/Mg 9.1/3. 6 mg/dL Uric acid 2.4 mg/dL Choleterol 189 mg/dL Glucose 446 mg/dl CK/LD 436/197 IU/L HbA1C 14.5 (%) CRP 0.3 mg/dL 3. U/A RBC 0-1/HPF WBC 0-1/HPF SG 1.051 protein/glucose/nitrite(-/4+/-) Total cholesteol 189 TG 46 LDL 94 HDL 72 T3 120 ng/dL Free-T4 0.90 ng/dL TSH 2.24 μU/mL

8. Initial Assessment 8 #1. Uncontrolled DM S) Wt.loss (+) Polyuria (+) Polydipsia (+) Decreased visual acuity (+) O) DM 진단 : 02’ (36 세 진단됨 ) Family history (-) DKA / HHS (-/-) HbA1C : 14.5 % BMI : 18.1 kg/m 2 Random glucose 445 Urine glucose 4+ A) Uncontrolled type Ⅱ DM r/o LADA (late autoimmune diabetes on adult)

9. Latent autoimmune diabetes in adults 9 DIABETES CARE, VOLUME 32, SUPPLEMENT 2, NOVEMBER 2009 1. onset at an adult age (>35 years) 2. Presence of specific autoantibodies (GAD, IAA, IA2) 3. Latency (≥ 6 months) between diagnosis and the need to require insulin therapy

10. Initial Plan 10 P) Diagnostic plan OGTT & insulin secretion test or Glucagon stimulation test Auto Ab Test (anti GAD-Ab, anti IA2-Ab.) DM Complication Test Therapeutic plan MDI [ Levemir(Insulin detemir) + novorapid(Insulin aspart) ]

11. Glucagon stimulation test 11 C-peptide (ng/ml) 참고치 (ng/ml) 0 min0.1 0.78-1.89 ng/mL 6 min0.3 4 ～ 10 ng/mL

12. Auto antibody test 12 참고치결과값 Anti GAD-Ab ~ 1.00 U/ml1.40 U/ml Anti IA2-Ab ~ 0.4 U/ml< 0.4 U/ml

13. Fundoscopic finding 13 Lt. eye Rt. eye

14. Clinical course 3/22~3/23 Levemir 14u (pm 9:00) + humalog 10u ( 매식전 ) 3/24~3/27 Levemir 16u (pm 9:00) + humalog 12u ( 매식전 ) 25

15. 15           Final Diagnosis  LADA (late autoimmune diabetes on adult) !! Anti GAD-Ab (+), Anti IA2-Ab (-) Glucagon stimulation test  현저히 저하된 C-peptide level Family history (-)  BMI : 18.1 kg/m 2 DM 진단 : 02’ (36 세 진단됨 )  Uncontrolled DM with OHA