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A 17 years old girl was born on term. At the age of 2 years, the girl went into an unconscious state and admitted to a hospital. Laboratory diagnosis represented severe level of diabetic ketoacidosis (Nagy et al., 2010). Some important signs of diabetic ketoacidosis are abdominal pain, hypotension, rapid shallow breathing, and dehydration (Buttaro, 2013). Blood glucose level of the girl was 37.6 mmol per liter. After thorough diagnosis, type 1A diabetes was found and she was given insulin treatment (Nagy et al., 2010).
At the age of 11 years, she became pale and started complaining fatigue and constipation. Her school performance also deteriorated. Her diagnosis showed elevated levels of thyroid peroxydase, thyroglobulin and thyroid stimulating hormone (TSH) receptor antibodies. TSH level was 100 μU/L, and thyroglobulin was 4744 U/mL. Thyroid hormone levels of the girl were consistent with that of autoimmune hypothyroidism. She showed moderate thyromegaly and usual features of chronic thyroiditis. With the help of thyroid replacement therapy, the growth rate of the girl accelerated and she started living without symptoms (Nagy et al., 2010). It is also important to note that thyroid disease can severely affect the control of diabetes. Decreased levels of thyroid hormones could result in prolonged insulin half-life, decreased insulin secretion, and decreased insulin levels that could lead to decreased insulin requirements. Usually, glucose levels stabilize during hypothyroidism treatment, but once the thyroid function is stabilized, glucose levels could be increased; thereby, requiring appropriate control (Johnson, 2006).
At the age of 15 years, the girl started complaining about backache along with painful swelling of the knees. Upon examination, it was found that both knees were larger in size showing intra-articular fluid retention as well as limited movement. Laboratory diagnosis showed slightly elevated levels of erythrocyte sedimentation rate, i.e. 36 mm/h, when normal is less than 12 mm/h; the C3-complement levels, and the C-reactive proteins, i.e. 6.6 mg/mL, when normal is less than 5.0 mg/mL. Use of non-steroidal anti-inflammatory drugs along with methylprednisolone and methotrexate helped in remission for 2 years. Stoppage of therapy lead to relapse of inflammation in the left knee; thereby, requiring a newer course of medical therapy (Nagy et al., 2010). Liao et al. (2009) also reported the association of rheumatoid arthritis with diabetes, and noted that insulin along with other medications have no association with rheumatoid arthritis.
After considering this history, medical specialists gave the girl 62 units of insulin on daily basis; 75μg of thyroxin on daily basis, and 12.5mg of methotrexate on weekly basis (Nagy et al., 2010). However, Rekedal et al. (2010) found that methotrexate is a potent disease modifying anti-rheumatic drug as compared to hydroxychloroquine and is related to more reduction of glycated hemoglobin; so, hydroxochloroquine could also be considered for treatment of the girl.
The girl was found to have genetic problems. It was noted that HLA class II genes, CTLA4 genes, and the PTPN22 genes and some of their variants were involved in the above mentioned issues, and could increase the chances of diabetes and other above mentioned diseases. These genes could positively or negatively regulate T-cell activation and could show various autoimmune phenotypes. This finding is also showing that diabetes could occur with various other autoimmune disorders that are hereditary. These diseases may have a common genetic background. Moreover, diabetes usually occurs firstly and then other problems arise (Nagy et al., 2010).
References
Buttaro, T. M. (2013). Primary Care: A Collaborative Practice: Elsevier/Mosby.
Johnson, J. L. (2006). Diabetes control in thyroid disease. Diabetes Spectrum, 19(3), 148.
Liao, K. P., Gunnarsson, M., Källberg, H., Ding, B., Plenge, R. M., Padyukov, L., . . . Alfredsson, L. (2009). A specific association exists between type 1 diabetes and anti-CCP positive rheumatoid arthritis. Arthritis and rheumatism, 60(3), 653.
Nagy, K. H., Lukacs, K., Sipos, P., Hermann, R., Madácsy, L., & Soltesz, G. (2010). Type 1 diabetes associated with Hashimoto's thyroiditis and juvenile rheumatoid arthritis: a case report with clinical and genetic investigations. Pediatric diabetes, 11(8), 579-582.
Rekedal, L. R., Massarotti, E., Garg, R., Bhatia, R., Gleeson, T., Lu, B., & Solomon, D. H. (2010). Changes in glycosylated hemoglobin after initiation of hydroxychloroquine or methotrexate treatment in diabetes patients with rheumatic diseases. Arthritis & Rheumatism, 62(12), 3569-3573.
