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Discovery Curriculum:

M2 Pathophysiology
Type 1 Diabetes in Pediatric Patients

Handout -Session 5c February 3, 2014 Monday PM


Hour 4: T1DM pediatric Auble

Pathophysiology of T1DM in children

Natural history of type 1


diabetes

Epidemiology of T1DM

Some common electrolyte changes


in untreated T1DM:
Hyponatremia osmotic dilution of
plasma
Hypokalemia not a consistent
finding
Low carbon dioxide (i.e.
bicarbonate) ketoacidosis
Phosphate: decreased phosphate
intake and phosphaturia

Biochemistry of Ketoacidosis

Insulin overdose
Insulin overdose causes hypoglycemia (blood sugar <70
mg/dL). This can cause mild symptoms of shakiness,
headaches, dizziness, sweatiness, tachycardia, hunger, or
fatigue. It is the response to increased sympathetic tone. It
is treated with oral fast-acting carbohydrates (juice, candy)
and rechecking blood sugar in 15 minutes until rising.
If patient has moderate hypoglycemia, which causes
neuroglycopenic symptoms, patients experience confusion,
combativeness, poor coordination, slurred speech. Treatment
usually includes fast-acting carbohydrates, such as frosting or
sugar-gel, given orally or in the buccal mucosa.
For severe hypoglycemia, which results in stupor, seizure,
and coma, patients should receive emergency care with
glucagon injections (after EMS is called).

Session 5c Bethany
Auble, MD
Auble/5c/T1D peds

Case
You are seeing Bobby, a 7-year-old boy, in your
outpatient clinic for concerns of fatigue and
increased thirst. Mother reports he has had less
energy than usual, and unable to keep up with his
peers. His appetite has been good. He has had a
recent growth spurt but his weight has remained
the same. You probe further and find he has had 2
episodes of bedwetting over the last 2 weeks. He
has been potty trained since 4 years of age and
has not had any accidents since then. Mom
believes his clothes have become loose in the
past several weeks.

Case Question 1
You suspect Type 1 diabetes mellitus. Understanding
the pathophysiology of the disease, which would
be most consistent with this diagnosis?
1. Pancreatic alpha cells are systematically
destroyed
2. Bobby ate too many Christmas cookies
3. **TH1 and CD8-mediated destruction of beta
cells.
4. Insulin resistance led to inability to respond to
carbohydrates.
5. His bedwetting is due to vasopressin deficiency.

Case - continued
You obtain the following fasting
laboratory tests:
Glucose 534 mg/dL (60100)

Chloride 112 mEq/L (98108)

Sodium 131 mEq/L (135145)

Creatinine 0.9 mg/dL (0.51.06)

Potassium 5.5 mEq/L (3.55)

Hemoglobin 13.5 g/dL


(10.5-14)

Carbon dioxide 19 mEq/L


(20-28)

Urine specific gravity 1.015


(1.001-1.035)

Case Question 2
What is the best course of treatment
for Bobby?
1. **Glargine and lispro insulin
2. Metformin therapy
3. Diet and exercise
4. Glipizide
5. Glitazone

Case Question 3
Which of the following would be a better
choice for a bedtime snack for 30g?
1. 2 pieces of white toast
2. 8 oz. orange juice
3. **10 Triscuit crackers with cheese
slices
4. 30 Skittles
5. Diet caffeine-free coke

Pearls for T1DM (Pediatrics)


Type 1 Diabetes is an autoimmune diseases caused
by T Helper (TH1) cell-recruitment of cytotoxic CD8
cells and destruction of beta-cells with cytokines.
Symptoms of T1DM include increased thirst,
urination, hunger, weight loss and fatigue.
Diagnosis is made by a random blood glucose >200
mg/dL, two fasting blood glucose values of >126
mg/dL, or a positive oral glucose tolerance test
Diabetes ketoacidosis (DKA) is characterized by
severe hyperglycemia, ketoacidemia, and
dehydration leading to hypovolemic shock.
The most common regimen of insulin is multiple
daily injections (MDI): long-acting insulin, such as
glargine or detemir, and short-acting insulin with
meals, such as lispro or aspart.

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