1. Case 2. History: 12 year old girl present with h/o 4 – 5 kg weight loss, over last few weeks, with nausea, Increased thirst, increase urination. Past History: No major illness in past. Family History: No family members with h/o Diabetes

2. Personal History: Not significant, O/E: Weight : 25 kg Height: 135 cm Pulse: 80/min Regular BP : 110/70 mm of hg. Thin, CVS/RS/AS/CNS : Normal Peri Pulse: Normal felt Feet / Nails / Sensation : clinically Normal Mucous membranes : dry

3. Laboratory Ix: 1. Hb : 13.7 %, CBC: 11,600 TC 2. RBS: 421 mg/dL 3. Urine Sugar: ++++, Urine Acetones: ++ 4. S. Ketones: Positive 5. Urea: 24 mg/dL, S. Creat: 0.8 mg/dL 6. Electrolyte: Na: 129, K: 3, Cl: 93 mEq/L 7. Hco3 : 23 mEq/L

4. Q: 1. Based on Above History what is Provisional Diagnosis? 1. Type 1 DM 2. Type 2 DM 3. MODY 4. None of the above.

5. Why Type 1 : 1. Early Onset : child / adolescence 2. No Family History 3. Classical History: 3 Poly with weight loss 4. Thin 5. Ketonuria / Ketosis : abrupt / rapid onset

6. What are Various clinical presenting Symptoms in Type 1 DM ?

7. 6. Confirmation needed ? Auto antibodies test: GAD 65 (Glutamic acid Decarboxylase) ICAs (Islet cell antibody: 5 yr prediction marker) IA2 (Insulin Antibody) C peptide level : low to absent. (fasting or postprandial) 2 to 4.5 1.2 to 3.4 0.4 to 2.1 Adult 2 to 4.5 1.2 to 3.4 0.4 to 2.2 Child ( < 15 yr) PP 2 Hr level After Glucose load PP 2 Hr level After Meal Fasting level “ C” peptide level : Unit :nano gm/ml

8. Are there any further classification: in Type 1? a. Type 1 (a) : when AB are positive. b. Type 1 (b) : when AB are negative, So Idiopathic in origin Very rare

9. Q : 2 In Type 1 DM: 1. Immune mediated destruction of Pancreatic B cells. 2. IR 3. Both of the above 4. None of the above.

10. Analysis: 1. In Type 1 Insulin deficiency is absolute, due to absence / destruction / loss of B cells of Islets of Langerhans of Pancreas. 2. Autoimmune destruction of Pancreatic B cells is due to environmental factors interacting with genetic susceptibility. 3. when there is ~ 90 % autoimmune destruction of B cells, absolute insulin deficiency results. 4. Environmental factors are : Infection and Diet Viral infection play important role by initiating / modifying autoimmune process. 5. Genetic factors: HLA (Human Leukocyte antigen) class II molecule DR3 and DR4 are associated with Type 1.

11. What else need to be Investigated? 1. Micro vascular complication: Retinopathy : Fundus Nephropathy : Urine Proteins, S. creatinine, Microalbuminuria. Neuropathy : 2. Macro vascular complications: CV status : Heart and Brain : ECG, PV status 3. Lipid profile.