A 16-year-old girl is brought to the office for evaluation of hyperglycemia. A week ago, the patient was seen at an urgent care clinic due to vaginal discharge and dysuria. She was diagnosed with candidal vulvovaginitis, and her urine dipstick was positive for glucose and negative for ketones. Finger-stick blood glucose was 200 mg/dL and a subsequent hemoglobin A1c level was 7.6%. The patient has been excessively thirsty over the past several weeks but has had no abdominal pain, nausea, or vomiting. She has no previous medical conditions and takes no medications. Family history is significant for diabetes mellitus and hypertension in both parents. Vital signs are within normal limits and BMI is at the 95th percentile for her age. Which of the following findings is most likely to be observed in this patient?

Question

A 16-year-old girl is brought to the office for evaluation of hyperglycemia.  A week ago, the patient was seen at an urgent care clinic due to vaginal discharge and dysuria.  She was diagnosed with candidal vulvovaginitis, and her urine dipstick was positive for glucose and negative for ketones.  Finger-stick blood glucose was 200 mg/dL and a subsequent hemoglobin A1c level was 7.6%.  The patient has been excessively thirsty over the past several weeks but has had no abdominal pain, nausea, or vomiting.  She has no previous medical conditions and takes no medications.  Family history is significant for diabetes mellitus and hypertension in both parents.  Vital signs are within normal limits and BMI is at the 95th percentile for her age.  Which of the following findings is most likely to be observed in this patient?

Quizplus · Accepted Answer

This patient with a new diagnosis of diabetes mellitus (elevated hemoglobin A1c level, symptomatic hyperglycemia [eg, polydypsia], vulvovaginal candidiasis) likely has type 2 diabetes. Although type 2 diabetes is more common in older individuals, the incidence in adolescents and young adults is increasing in association with a rise in childhood obesity (eg, BMI ≥95th percentile for age). Excess adiposity contributes to insulin resistance, which is aggravated by rising growth hormone levels at puberty. A positive family history of diabetes increases the risk; the incidence is also higher in certain racial and ethnic groups (eg, black and Native American patients). Other findings associated with insulin resistance include central (visceral) obesity, elevated blood pressure, and lipid abnormalities (eg, hypertriglyceridemia, decreased HDL levels). In addition, insulin resistance in type 2 diabetes can be associated with the extensive development of acanthosis nigricans, which presents as velvety, hyperpigmented patches in intertriginous areas (eg, neck, axillae). hyperpigmented patches (Choice A) Growth hormone-secreting pituitary adenomas can cause diabetes, and bitemporal hemianopia can occur due to compression of the optic chiasm. However, patients typically display gigantism or acromegaly rather than obesity. acromegaly (Choice B) Chronic pancreatitis can lead to exocrine pancreatic insufficiency with steatorrhea, and loss of beta cells can cause secondary diabetes. However, this is much more common at age >30 and is typically associated with chronic abdominal pain, nausea, and weight loss. (Choice D) Glucokinase gene mutations are a cause of maturity-onset diabetes of the young, which is characterized by decreased secretion of insulin at any given glucose level. However, patients are typically not obese and the hyperglycemia is usually mild (<140 mg/dL). (Choice E) Pancreatic autoantibodies can cause loss of islet cells, leading to type 1 diabetes. In type 1 diabetes, there is an absolute insulin deficiency (rather than a relative deficiency, as in type 2 diabetes), which leads to increased production of ketones and, potentially, diabetic ketoacidosis. Typical features include rapid-onset hyperglycemia, ketonuria (which is absent in this patient), hyperventilation, and abdominal pain. Educational objective: The incidence of type 2 diabetes in adolescents and young adults is increasing in association with a rise in childhood obesity. Excess adiposity contributes to insulin resistance, which is aggravated by increasing growth hormone levels at puberty. Other findings seen with insulin resistance include acanthosis nigricans, central obesity, elevated blood pressure, and lipid abnormalities. References: Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/23359574)

A 16-Year-Old Girl Is Brought to the Office for Evaluation