Case Study Analysis

On Type I Diabetes Mellitus

In Partial Fulfillment of the Requirements

In

Bio 306: Immunology

Presented to

Prof. Jeannemar Genevive Figueras

Biological Science Instructor

Submitted by

Precious Carnel Legayada

Louregine S. Navarra

BS Biology (Premed)

October 2015
I. Background and Prognosis

Type I Diabetes Mellitus is a chronic autoimmune disease

that occurs in a genetically susceptible individual as a result

of environmental factors (Nakamura, 2000). Approximately 10

percent of patients with diabetes mellitus have the immune-

mediated disease (Burek et. al., 2006).

It is characterized by insufficient insulin production

caused by selective destruction of the beta cells of the

pancreas. Beta cells are located in the pancreas in clusters

called islets of Langerhans. Family studies indicate that there

is an inherited genetic susceptibility to the disease, probably

attributable to multiple genes (Powers, 2005).

Type I Diabetes Mellitus can occur at any age. It is most

common in juveniles but can also develop in adults, especially

in those in their late 30s and early 40s (Burek et. al., 2006).

Unlike people with Type II Diabetes Mellitus, those with Type I

Diabetes Mellitus usually are not obese and usually present

initially with diabetic ketoacidosis (DKA). The distinguishing

characteristic of a patient with Type I Diabetes Mellitus is

that if his or her insulin is withdrawn, ketosis and eventually

ketoacidosis develop. Therefore, these patients are dependent on

exogenous insulin.
 It is associated with a high morbidity and premature

mortality. More than 60% of patients with type 1 DM do not

develop serious complications over the long term, but many of

the rest experience blindness, end-stage renal disease (ESRD),

and, in some cases, early death. The risk of ESRD and

proliferative retinopathy is twice as high in men as in women

when the onset of diabetes occurred before age 15 years

(Tamborlane et. al., 2008).

II. Patient History

A 19 year old female nursing student of Central Philippine

University was diagnosed with Type I Diabetes Mellitus. She was

10 years of age when symptoms of the disease was observed. She

experienced severe weight loss and increased urination

especially at night, thus causing her sleep disturbances. For

three months, her mother has checked her blood sugar level

regularly, hoping the symptoms would soon recede. But soon

after, the patient consulted a physician.

Family history of the patient indicates she is susceptible

to diabetes. Her mother, who died last 2007 because of an end-

stage kidney failure, has a juvenile Type I Diabetes Mellitus

and her father has an acquired Type II Diabetes Mellitus. Two of

her cousins have Type I Diabetes Mellitus as well, although her

siblings are negative for diabetes.

III. Diagnosis

Laboratory tests taken by the patient includes Fasting

blood sugar (FBS) and test for Glycosylated hemoglobin

(Hemoglobin A1c) with the result of 9.5% deviating from the

normal range of 4-5.6%.

This test examines blood levels of glycosylated hemoglobin,

also known as hemoglobin A1c (HbA1c). The test is not affected

by recent food intake so it can be taken at any time. The

results of a blood glucose test tell the patient and doctor how

well the diabetes is controlled for only the day of the test.

Once a blood sugar molecule sticks to a hemoglobin

molecule, which is found in every red blood cell, it never lets

go (a process called glycation). If a patient with diabetes has

elevated blood glucose on many days, more blood glucose

molecules will stick to the hemoglobin molecule. If that

happens, the hemoglobin A1c level will be higher. Therefore, an

elevated hemoglobin A1c level tells the doctor and the patient

how well controlled the patients diabetes has been over the last

3 months or so (Jacobson et. al., 2007).

 Measuring glycosylated hemoglobin is not generally used for

making an initial diagnosis of diabetes, since a normal level

does not rule out diabetes. In people without diabetes, a normal

HbA1c range is between 4 - 6%. Elevated levels of glycosylated

hemoglobin are strongly associated with most if not all of the

complications of diabetes (Drueke et. al., 2006).

In general, most adults with diabetes should aim for HbA1c

levels below 7%. Higher levels indicate poor blood glucose

control (Drueke et. al., 2006).

IV. Treatment

Insulin cannot be taken orally because the body's digestive

juices destroy it. Injections of insulin under the skin ensure

that it is absorbed slowly by the body for a long-lasting

effect. The timing and frequency of insulin injections depend

upon a number of factors such as the duration of insulin action

since insulin is available in several forms, including:

standard, intermediate, long-acting, and rapid-acting. Other

factors are amount and type of food eaten since ingestion of

food makes the blood glucose level rise while alcohol lowers

levels and lastly, the person's level of physical activity since

exercise lowers glucose levels.

 The patient is currently taking insulin four times a day

with Lantus before bedtime, Humalog after meals.

Insulin lispro (Humalog) is a fast-acting insulin that

lowers blood sugar very quickly, usually within 5 minutes after

injection. Insulin peaks in about 4 hours and continues to work

for about 4 more hours. This rapid action reduces the risk for

hypoglycemic events after eating (postprandial hypoglycemia).

Optimal timing for administering this insulin is about 15

minutes before a meal, but it can also be taken immediately

after a meal (but within 30 minutes). Fast-acting insulins may

be especially useful for meals with high carbohydrates (Jacobson

et. al., 2007).

Long-acting insulins, such as insulin glargine (Lantus),

are released slowly. Insulin glargine matches parts of natural

insulin and maintains stable activity for more than 24 hours.

Studies suggest that it poses less of a risk for hypoglycemia

and weight gain than NPH. It has a higher incidence of pain at

the injection site than NPH. Ultralente insulin peaks at 10

hours and lasts up to 20 hours but varies greatly in activity

from day to day (Jacobson et. al., 2007).

The patient follows a treatment goal of achieving near-

normal blood glucose levels by coordinating calorie intake with

medication or insulin administration, exercise, and other

variables. She also monitors her blood sugar for signs of

possible hypoglycemia or hyperglycemia.

V. Prognosis

Type I Diabetes Mellitus is a lifelong chronic condition

thus requires a lifelong insulin therapy. The patient is not

currently experiencing complications or other conditions aside

from diabetes.

VI. Conclusion

The disease acquired by the patient is mainly caused by

genetic factors since most of her family members have the same

disease. According to Alemzadeh (2007), patients with this type

who survive the period 10-20 years after disease onset without

fulminant complications have a high probability of maintaining

reasonably good health. Other factors affecting long-term

outcomes are the patient’s education, awareness, motivation, and

intelligence level.
References

Alemzadeh, R. and Wyatt, D. T. Diabetes mellitus. In: Kliegman

RM, ed. Nelson Textbook of Pediatrics. 18th edition.

Saunders; 2007.

Burek, C. L., Bigazzi, P. E., & Rose, N. R. (2006).

Endocrinopathies. In B. Detrick, R. G. Hamilton, & J. D.

Folds, Manual of molecular and clinical laboratory

immunology (7 ed., pp. 1062-1077). Washington, DC: ASM

Press.

Diabetes Control and Complications Trial/Epidemiology of

Diabetes Interventions and Complications Study Research

Group, Jacobson, A. M., Musen, G., Ryan, C. M., Silvers,

N., Cleary, P. Long-term effect of diabetes and its

treatment on cognitive function. N Engl J Med. 2007 May

3;356(18):1842-52.

Drueke, T. B., Locatelli, F., Clyne, N., Eckardt, K. U.,

Macdougall, I. C., Tsakiris, D. Normalization of hemoglobin

level in patients with chronic kidney disease and anemia. N

Engl J Med. 2006 Nov 16; 355(20):2071-84.

Juvenile Diabetes Research Foundation Continuous Glucose

Monitoring Study Group, Tamborlane, W. V., Beck, R. W.,

Bode, B. W., Buckingham, B., Chase, H. P. Continuous

 glucose monitoring and intensive treatment of type 1

diabetes. N Engl J Med. 2008 Oct 2; 359(14):1464-76.

Nakamura, R. M. (2000). Human autoimmune disease: Progress in

clinical laboratory tests. MLO, 32, 32-45.

Powers, A. C. (2005). Diabetes mellitus. In D. L. Kasper, E.

Braunwald, A. E. Fauci, & S. L. Hauser, Harrison's

principles of internal medicine (16 ed., pp. 2152-2179).

New York: McGraw-Hill.