Type III PAS is defined as autoimmune thyroiditis occurs with another organ-specific autoimmune disease. Further PAS IIIA is subclassified as autoimmune thyroiditis with immune-mediated diabetes mellitus. Circulating organ-specific autoantibodies can be detected in these patients. We report a patient with Hashimoto Thyroiditis since five years on levothyroxine treatment with normal TSH levels and new onset insulin dependent Type I DM for 3 months. The patient was admitted Recurrent Diabetic Ketosis and succesfully treated by switching Analog insulin to Human Insulin. Analoginsulin Induced Anti-InsulinAntibody was thought to be the cause. 43-year-old female patient admitted to our hospital with diabetic ketoacidosis. She was treated with four times daily insulin injections with insulin aspart before meals and insulin detemir at bedtime. She did not miss any dose or there were no identified underlying cause for ketosis. She weighed 48.3 kg with BMI: 20.63 kg/m2 and physical examination revealed no pathologic findings. Laboratory evaluation showed markedly increased HbA1c (10,5) levels together with decreased C-peptide levels (0.51 ng/ml). An autoimmunity screening was performed: antiGAD (51.27 IU/ml) and antiICA(+1) have positive results as suggesting the Type I DM. We started to insulin infusion with reguler insulin untill plasma ketones were negative. Insulin detemir and aspart were initiated as intensive treatment. Dose titration performed according to 7 point daily glucose monitorisation for a week. She has been treated with five daily insulin injections: 75 units of aspart and 60 units of detemir daily. Nevertheless her blood glucose levels were 200310 mg/dl with this treatment. Consequently we started to insulin infusion with reguler insulin again. In the first hours of the regular infusion hypoglycemia developed with 4units/hour dosage. Anti-insulin antibody level was markedly elevated. (15U/ml; normal, <10 U/ml). We switched the treatment to regular and NPH insulin. Afterwards, her blood glucose quickly normalized and daily insulin need was decreased significantly to 5055 units. She was discharged with regular insulin and NPH treatment. HbA1c level was 7.5% on third month follow-up. Immunological insulin resistance, which is characterized by a requirement for an insulin dosage over 120 U/day due to anti-insulin antibodies has since become quite rare. In the few reported cases, patients were treated with glucocorticoids or plasmapheresis Recently we succesfully treated a patient with severe immunological insulin resistance due to antibodies by modification of insulin administration; Analog insulin to Human Insulin.
19 May 2018 - 22 May 2018