Pitfalls in establishing type of diabetes and optimal therapy: Clinical cases series

Type 1 diabetes is an autoimmune disease characterized by absolute endogenous insulin deficiency. We report three clinical cases which highlight the particularities of diagnosis and evolution of patients with type 1 diabetes. These three cases have been diagnosed in different circumstances. The first case with symptoms of hyperglycemia and inaugural diabetic ketoacidosis, without detecting a precipitating factor; the second case accidentally diagnosed, in the absence of hyperglycemia symptoms; and the last case in the context of symptoms of hyperglycemia and ketosis precipitated by a respiratory infection. The cases are characterized by the presence of autoimmunity markers (anti-GAD positive antibodies) and C peptide within normal range. In dynamics, with the initiation of insulin therapy and the remission of glucotoxicity, the insulin requirement decreased progressively, in all patients therapeutic regimen being represented by a low dose of basal insulin, in the conditions of a C peptide still within normal limits at 4 years (first case), one year (second case), respectively 2 years (third case) from the diagnosis and without significant glycemic variability registered on the continuous glycemic monitoring system. In the third case, there is a lack of regression of insulin requirements after remission of SARS COV-2 infection, and in the second case, the maintenance of prandial insulin secretion sufficient to induce hypoglycemia after administration of a minimal dose of prandial insulin, but insufficient to control postprandial glycemia in the conditions of omitting the administration of prandial insulin. In each of the cases previously presented we highlight the existing pitfalls in establishing the diagnosis and especially the challenges in choosing the optimal therapy in patients with type 1 diabetes, as the evolution can sometimes be atypical.