https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/3 Sat, 23 Jul 2016 08:26:58 +0000 A total number of 125 patients with diabetes mellitus (DM) under eighteen years of age were admitted in the Paediartic department of BIRDEM hospital between January 2001 to October 2002. Eighty-eight patients (71%) were newly detected. Female to male ratio was 3:1. Out of the total admission 38 (30.4%) patients had type 1 DM (group 1), 37 (29.6%) patients had fibrocalculous pancreatic FCPD diabetes (group II), 48 (38.4%) patient had malnutrition modulated diabetes mellitus MMDM (group III) and 2 (1.6%) patients had type 2. Mean age of onset was 9±3.9 yrs in group I and 13±2.3 yrs in group II and group III. All groups had very high glucose and HbA1c value at presentation. The mean fasting glucose (mmol/l) was 19±7.14, 22.39±9 and 19.54±7.9 in group I, group II and group III respectively. The Mean HbA1c (%) value in the three groups was 14.4±2.7, 16.72±2.26 and 15.27±3.05 respectively. FCPD patients had poorest glycaemic status. Acute complications were more common in type 1 patients. Twelve (31.5%) patients had diabetic ketoatin DKA and two (5%) patients had hypoglycaemia in group I. Chronic complications were present in all three groups.  MMDM patients had highest rate of complications. which was present in 2.6%, 21.6% and 33.3% patients in group I, group II and group III respectively. The rate of microalbuminuria was 5.3%. 10.8% and 18.8% in the three groups respectively. The rate of neuropathy was 2.6%, 16.2% and 20.8% in the three groups respectively. Among the associated problems skin infection, pulmonary tuberculosis and bilateral parotid swelling were common. Malnutrition was present in 66%, 86% and 100% in group I, group II and group III respectively. Majority (50% in group I, 91.6% in group II and 100% in group III) of our patients came from poor socio-economic background. Ibrahim Med. Coll. J. 2007; 1(1): 11-15 Introduction Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic disorders (BIRDEM) is an internationally reputed tertiary level hospital for care of diabetic patients. By the end of 2003, the number of registered diabetic patients in BIRDEM was 320,000. The proportion of diabetics under eighteen years of age was found to be 1.58% among the registered cases of BIRDEM. It is expected that the under eighteen registered diabetic patients in BIRDEM represent the population of childhood and adolescent diabetics of Bangladesh. The present study was undertaken to examine the clinical profile of DM in children and adolescents in the Department of Paediatrics, BIRDEM. Patients and Methods 1.   Type 1 DM (group I): Patients with early onset and/or with typical sign/symptoms of diabetes for a short duration were classified as type 1 diabetics. Patients presenting with diabetic ketoacidosis (DKA) were also included in this group. 3.   MMDM (group III): Patients with lean body mass (BMI less than 5th centile for age), other evidence of malnutrition and no pancreatic calcification. They had signs/symptoms of diabetes for prolonged period but absence of ketosis. Microalbuminuria was defined as albumin/creatinine ratio (ACR): 30-300mg/gm in spot urine. All the data were expressed as mean±standard deviation, median (range) and/or number (%) as appropriate. Statistical analysis was done by using SPSS for windows package. Appropriate statistical test of significance like unpaired t test was used as necessary. P<0.05 was taken as minimal level of significance. Correlation study was done by Pearson correlation. Results All patients in group II and group III had typical symptoms of diabetes at diagnosis. In addition, 32% of FCPD patients had history of recurrent abdominal pain. One patient in group I had nocturnal enuresis as the only presenting symptom. Seven (24%) of type 1 diabetic patients developed DKA at first presentation, six of them had typical symptoms of DM for a short period (few days to few weeks) before developing DKA, but one patient presented with DKA only without preceding symptoms of diabetes. A substantial number of patients presented themselves with chronic complications such as cataract, microalbuminuria and neuropathy at diagnosis. Out of 25 cases of cataract, 16 (64%) cases were newly detected. Ten (66%) out of fifteen patients with microalbuminuria and 12 (70%) out of seventeen patients with neuropathy were newly detected. Among the newly detected patients mean(±SD) duration (months) of  typical symptoms of DM prior to diagnosis was 2.0 ±2.9, 6.3 ± 9.6 and 13 ±12  in group I, group II and group III respectively. There was significant difference in duration of symptoms among the three groups (p=0.02 in group I vs. group II; p<0.0001in group I vs. group III; p=0.03 in group II vs. group III). MMDM group had longest duration of typical symptoms of diabetes.     Glyacemic control Group II Fasting blood glucose (mmol/l) 22.39±9 Blood glucose 2 hour after breakfast ( mmol/l) 31.07±7.1 HbA1c (%) 16.72±2.26   Acute complications were more common in type 1 patients. In group I, twelve (31.5%) patients had DKA and 2 (5%) patients had hypoglycaemia. The first presentation was with DKA in seven (24%) type 1 diabetic patients. Only one (2.7%) FCPD patient had DKA along with septicaemia.   No significant correlation was found between any of the complication and duration of diabetes, duration of symptom, glycaemic status, age of onset or age on admission. There were some associated problems as shown in table 2. Table 2. Distribution of associated problems as among the three groups Group Group III 1 (2.6%) 7 (14.6) 19(2.6%) 5 (10.4%) 0 12 (25%) Family history of diabetes was present in eight (22.2%) type 1, one (2.6%) FCPD and three (8.1%) MMDM patients. Majority (50% in group I, 91.6% in group II and 100% in group III) of our patients came from poor socio-economic background. During the study period 2 patients died. One patient with type 1 DM died of DKA. One patient with FCPD died of septicaemia and pneumonia. She developed DKA before death. Discussion There was a female preponderance, consistent with our previous studies in BIRDEM8. Patients in FCPD and MMDM groups were mostly adolescents (mean age 13±2.3 years). In the majority of FCPD patients diagnosis is made between the ages of 20 and 40 years of age but onset in childhood, in infancy and at older age groups are not uncommon9-11. Onset of MMDM is commonly between 10 to 30 years but onset at preschool age and over the age of 30 years can also occur7. There is said to be a bimodal distribution for type 1 diabetics, with a minor peak at 4 to 6 years and a major peak at 10 to 14 years. In our study population, the mean age onset of type 1 diabetics was 9±3.9 years. The very high blood glucose and HbA1c in the three groups is not unexpected, as most of these are values at first presentation of diabetes. Glycaemic control was worst in FCPD patients. A striking feature of our study population was the presence of microvascular complications (microalbuminuria and neuropathy) even at presentation and a very high rate of complication in the MMDM group. Possible explanation is that they may have very slow onset diabetes or have remained undiagnosed for a long time. This is possible because despite having severe hyperglycaemia they are ketosis resistant19. Positive family history was present in 22.2%, 2.7% and 8.1% Type 1, FCPD and MMDM patients respectively. Although genetic factor is important for the development of type 1 diabetes, positive family history is uncommon (<10%) in MMDM suggesting that the disease is more likely environmental than genetic 7. Familial aggregation of FCPD patients have been reported from India and Bangladesh suggesting genetic susceptibility21,22.   The overall clinical presentation of our diabetic population is somewhat different from that of developed and western world. Acute complications such as DKA and hypoglycaemia are more common in Type 1 patients as found worldwide but the high rate of complication even at presentation among FCPD and MMDM patients and their poor nutritional status are of concern.   1.    Ruwaard D, Hirasing RA, Reeser HM et al. Increasing incidence of type 1 diabetes in the Netherlands. The second nationwide study among children under 20 years of age. Diabetes care 1994; 17: 599-601. 3.    WHO technical report series 727. Diabetes Mellitus. World Health Organization, Geneva, 1985. 5.    Tripathy BB, Samal KC. Overview consensus statement on Diabetes in Tropical areas. Diabetes /Metab Rev 1997; 13: 63-7. 7.    Samal KC, Kanungo A, Sanjeevi CB. Clinicoepidemiological and Biochemichal profile of Malnutrition-Modulated Diabetes Mellitus. Ann. N.Y. SCI. 2002; 958: 131-137. 9.    Mohan V, Ramachandran A,Viswanathan N. Childhood onset fibrocalculous pancreatic diabetes. Int J Diabetes  Dev Countries 1990; 10: 24-26. 11.  Mohan V, Suresh S, Indrani S et al. Fibrocalculous Pancreatic Diabetes in the elderly. J Assoc Phys Ind 1989; 37: 342-344. 13. Mohan V, SnehalataC, Ramachandran A et al. Plasma glucagons response in tropical fibrocalculous pancreatic diabetes. Diabetes res Clin Pract 1990; 9: 97-101. 15. Donaghue KC, Fairchild JM, Chan A et al. Diabetes complication screening in 937 children and adolescents. JPEM 1999; 12: 185-92. 17.  Ludvigsson J, Johanesson G, Heding L et al. Sensory nerve conduction velocity and vibratory sensibility in juvenile diabetics. Relationship to endogenous insulin. Acta Paediatr Scand 1979; 68: 739-48. 19.  Hugh-Jones P. Diabetes in Jamaica. Lancet 1955; 2: 891. 21. Chowdhury ZMd, McDermott MF, Davey S et al. Genetic susceptibility to fibrocalculous pancreatic diabetes in  Bangladeshi subjects: a family study. Genes and Immunity 2002; 3: 5-8. 2026 Ibrahim Medical College. All rights reserved.