Fulminant type 1 diabetes: Report of a new French Caucasian case and recent findings

Snap diagnosis of fulminant type 1 diabetes by the normalized glucose/HbA1c ratio

Elevated Fulminant Index (FI), [plasma glucose (PG)/glycosylated hemoglobin A1c (HbA1c)], was reportedly a sensitive index to differentiate fulminant type 1 diabetes (FT1D) from non-fulminant T1D (nFT1D). Aim of this study was to describe a better, but simpler index of FT1D. 49 and 52 patients with FT1D and nFT1D, respectively, were registered, and the discriminating ability of the rounded, normalized ratio, [PG (mmol/L) - 5.0]/[HbA1c (%) - 5.0], and the original ratio, [PG (mmol/L)]/[HbA1c (%)], was compared. Normalizing the ratio significantly raised its accuracy: area under the curve for receiver operating curve, AUROC (95%CI), 0.927 (0.858-0.964) and 0.851 (0.763-0.910), respectively, with and without the normalization (p < 0.01). Rounding of the figure into [PG (mmol/L) - 5.0]/[HbA1c (%) - 5.0] did not significantly sacrifice the discriminating ability of the index. Namely, the optimal cut point of rounded and normalized GAR, 10.0, showed 89.8% sensitivity. In conclusion, rounded, normalized (rn) GAR ≥10 (the rounded optimal cut-off) could be used for the snap diagnosis of FT1D.

Extensive-Disease Small-Cell Lung Cancer With Severe Immune-Related Adverse Events Due to Atezolizumab Maintaining a Complete Response for Two Years: A Case Report

A 75-year-old male with diabetes mellitus was referred to our hospital with an abnormal shadow on chest radiography, based on which he was diagnosed with extensive-disease small-cell lung cancer (ED-SCLC; cT2bN2M1a). The first-line therapy comprised atezolizumab, carboplatin, and etoposide. After four cycles, the patient achieved complete response (CR), and maintenance therapy was initiated with atezolizumab. However, even though CR was maintained, maintenance therapy was discontinued after 16 cycles due to persistent grade 2 anorexia and fatigue. Simultaneously, the HbA1c decreased to 5.5%, and antidiabetic therapy was discontinued. Six months after the last dose of atezolizumab, the patient visited the emergency room because of anorexia, dry mouth, and fatigue. Laboratory findings were as follows: blood glucose was 668 mg/dL, glycated hemoglobin (HbA1c) was 8.8%, urine ketone was 2+, sodium (Na) was 127 mmol/L, potassium (K) was 6.5 mmol/L, creatinine (Cre) was 1.43 mg/dL, and arterial pH was 7.29. Based on these findings, his presentation was consistent with fulminant type 1 diabetes mellitus (T1DM) complicated by diabetic ketoacidosis (DKA). Regular continuous insulin and saline administration was initiated in the intensive care unit, and acidosis and electrolyte abnormalities were corrected. His C-peptide was <0.03 ng/mL. His insulin secretory capacity was considered to be depleted, and he required continuous subcutaneous insulin injections. Glutamic acid decarboxylase and insulin autoantibodies were absent. The complete response persisted without further therapy until two years since the event.

Fulminant Type 1 Diabetes-East and West

Fulminant type 1 diabetes is a subtype of type 1 diabetes in which beta cells are destroyed within days or a few weeks. The first criterion indicates a rise in blood glucose levels shown in the patient's history. The second suggests that the increase occurs suddenly within a very short period, as shown by the laboratory findings of the discrepancy between the glycated hemoglobin concentration and plasma glucose level. The third indicates a marked reduction in endogenous insulin secretion, which indicates almost complete destruction of beta cells. Fulminant type 1 diabetes is a common subtype in East Asian countries, including Japan, but rare in Western countries. Class II human leukocyte antigen and other genetic factors may have contributed to the skewed distribution. Environmental factors may also be involved including entero and herpes viruses and immune regulation during drug-induced hypersensitivity syndrome; pregnancy may also affect it. In contrast, treatment with an immune checkpoint inhibitor of the anti-programmed cell death 1 antibody induces similar characteristics and incidence of diabetes as fulminant type 1 diabetes. Further studies are needed to clarify the etiology and clinical characteristics of fulminant type 1 diabetes. Although the incidence of this disease differs between the East and West, it is life-threatening; thus, it is important to diagnose fulminant type 1 diabetes without delay and treat it appropriately.

Prevalence and clinical characteristics of fulminant type 1 diabetes mellitus in Korean adults: A multi-institutional joint research

AIMS/INTRODUCTION

We aimed to determine the hospital-based prevalence and clinical features of fulminant type 1 diabetes mellitus in Korea.

MATERIALS AND METHODS

We identified all patients with diabetes who regularly visited the Endocrinology outpatient clinics at eight centers for a period >1 year between January 2012 and June 2017. We investigated their medical records retrospectively.

RESULTS

During this period, 76,309 patients with diabetes had been regularly followed up. Among them, 913 (1.2%) patients had type 1 diabetes mellitus . There were 462 patients with type 1 diabetes mellitus whose data at the time of the first diagnosis could be identified (359 and 103 with non-ketosis and ketosis onset, respectively). Of these, 15 (3.2% of type 1 diabetes mellitus, 14.6% of ketosis onset diabetes) patients had fulminant type 1 diabetes mellitus. The median ages at diagnosis were 40 and 27 years in the fulminant type 1 diabetes mellitus and non-fulminant type 1 diabetes mellitus groups, respectively. The patients with fulminant type 1 diabetes mellitus had higher body mass index, lower glycated hemoglobin and fasting/peak C-peptide, and lower frequent glutamic acid decarboxylase antibody-positive rate (P =0.0010) at diagnosis. Furthermore, they had lower glycated hemoglobin at the last follow-up examination than those with non-fulminant type 1 diabetes mellitus.

CONCLUSIONS

In this study, the prevalence of type 1 diabetes mellitus was 1.2% among all patients with diabetes, and that of fulminant type 1 diabetes mellitus was 3.2% among those newly diagnosed with type 1 diabetes mellitus. The glycated hemoglobin levels were lower in patients with fulminant type 1 diabetes mellitus than in those with non-fulminant type 1 diabetes mellitus at diagnosis and at the last follow-up examination.

Clinical Characteristics of Fulminant Type 1 Diabetes Compared with Typical Type 1 Diabetes: One-Year Follow-Up Study from the Guangdong T1DM Translational Medicine Study

BACKGROUND

Fulminant type l diabetes mellitus (FT1DM) is a subtype of type 1 diabetes mellitus (T1DM) with abrupt onset, but data on its progression was limited. This study was aimed at exploring the clinical features through one-year follow-up. Methods and Materials. Patients with T1DM finishing at least one-year follow-up from June 2011 to July 2018 were enrolled from Guangdong Type 1 Diabetes Translational Medicine Study. Patients who fulfilled the respective criteria were categorized as an FT1DM group and a typical T1DM group (TT1DM). The 1 : 4 propensity score matching based on onset age, duration, and gender was performed between the FT1DM and TT1DM groups. Characteristics at the onset and after one-year follow-up were compared between the two groups.

RESULTS

A total of 53 patients with FT1DM and 212 matched patients with TT1DM were included. At the onset, there was a shorter duration of symptomatic period before diagnosis observed in the FT1DM group than in the TT1DM group (2 [1, 7] vs. 30 [10, 60] days, P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (.

CONCLUSION

Patients with FT1DM had more severe metabolic derangement and deficiency of insulin secretion than patients with TT1DM at the onset, but glycaemic and metabolic control was not worse than that in TT1DM.