Remission of diabetes mellitus or honey moon phenomenon in a newly diagnosed young Nigerian. A case report

Henry Chijioke Onyegbutulem; Ambrose U Awogu; Jibril Y Abdulahi; Peace Ijeoma Henry-Onyegbutulem

doi:10.4103/ajem.ajem_9_21

CASE REPORTS

Year : 2022 | Volume : 12 | Issue : 1 | Page : 45-48

Remission of diabetes mellitus or honey moon phenomenon in a newly diagnosed young Nigerian. A case report

Henry Chijioke Onyegbutulem¹, Ambrose U Awogu², Jibril Y Abdulahi³, Peace Ijeoma Henry-Onyegbutulem⁴
¹ Department of Internal Medicine, College of Health Sciences Nile University of Nigeria, Abuja, Nigeria; Department of Internal Medicine, Asokoro District Hospital, Abuja; Abuja Clinics, Maitama Abuja, Nigeria
² Department of Internal Medicine, Asokoro District Hospital, Abuja, Nigeria
³ Department of Maxillofacial and Dental Surgery, Maitama District Hospital, Maitama, Abuja, Nigeria
⁴ Abuja Clinics, Maitama Abuja, Nigeria

Date of Submission	18-Aug-2021
Date of Decision	04-Jun-2022
Date of Acceptance	20-Jun-2022
Date of Web Publication	02-Sep-2022

Correspondence Address:
Dr. Henry Chijioke Onyegbutulem
Department of Internal Medicine, Asokoro District Hospital, PMB 230 Garki, Abuja, FCT
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajem.ajem_9_21

Abstract

Background: Diabetes Mellitus has since been recognised as a chronic metabolic syndrome referred variously as relentless and lifelong, requiring drugs for its control. However, studies are suggesting possible reversibility following appropriate and early interventions. Objective: To sensitize clinicians on the need for early and appropriate treatment intensification. This may not only help prevent long term complications but also offers an opportunity for remission. Materials and Methods: We report the case of an obese female teenager, who presented for the first time in coma with hyperglycaemia, and subsequent remission. Results and Interpretation: Early and intensive initiation of diabetes Treatment resulting in disease remission. Conclusions: Prompt initiation and Intensification of diabetes care including diet, lifestyle interventions and drugs is bound to ensure good outcomes including prevention of diabetes-related complications. In the course of this, remission may occur, especially in newly diagnosed young patients who don’t have organ damage yet.

Keywords: Care, diabetes mellitus, Nigerian, remission, young

How to cite this article:
Onyegbutulem HC, Awogu AU, Abdulahi JY, Henry-Onyegbutulem PI. Remission of diabetes mellitus or honey moon phenomenon in a newly diagnosed young Nigerian. A case report. Afr J Endocrinol Metab 2022;12:45-8

How to cite this URL:
Onyegbutulem HC, Awogu AU, Abdulahi JY, Henry-Onyegbutulem PI. Remission of diabetes mellitus or honey moon phenomenon in a newly diagnosed young Nigerian. A case report. Afr J Endocrinol Metab [serial online] 2022 [cited 2023 Jun 10];12:45-8. Available from: http://www.ajemjournal.org/text.asp?2022/12/1/45/355339

Introduction

Diabetes Mellitus has since been recognised as a chronic metabolic syndrome, referred variously as relentless and lifelong, requiring drugs for its control. However, studies are suggesting the possibility of reversal in some cases, if interventions are appropriate, intensive and early.^[1],[2],[3] Improvement of insulin sensitivity through weight regulation is thought to be a mechanism for remission.^[3],[4]

Case details

Y U is a seventeen-year-old female student admitted in coma with a history of polyuria and polydipsia that worsened one week prior to presentation. No personal or known family history of diabetes mellitus. No head injury or previous state of altered consciousness, no seizures or dysuria.

She was obese, dehydrated, not pale, anicteric with an entry blood glucose of 24.7mmol/l. Her blood pressure was 140/90mmHg. Respiratory rate, 32cpm, with acidotic breath. Anthropometric measures were; weight 100.2kg, Height of 1.70m, BMI of 34.7Kg/m2, waist circumference of 103 cm, Hip Circumference of 105 cm. Her Anion gap, Delta gap, Delta ratio and osmolality were 22.0mEq/l, 10.0mEq/l, 0.4mEq/l and 286.3mosm/kg respectively. A working diagnosis of hyperglycaemic emergency of the ketoacidotic type was entertained. There was dyslipidaemia, [Table 1]. She had insulin therapy, fluid replacement, electrolyte correction and antibiotics administration and regained consciousness the following day.

Table 1: Biochemical indices

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With the sustained clinical improvement and treatment intensification, she was discharged to the outpatient services two weeks later. Her discharge blood sugar was 7mmol/l with total daily insulin requirement of 70 iu, (premix 40iu-am and 30iu-pm). She also had statins. Lifestyle intervention (dietary prescription and physical exercise) were emphasised.

Six weeks after discharge, her blood sugar was stable at a weekly average of 5.1mmol/l while on a total daily insulin of 32iu. Insulin was discontinued and metformin introduced only to be discontinued on third month. Two years later, she is still on diet and exercise only, with average weekly blood glucose of 4.7mmo/l (fasting) and 5.7mmol/l (2-hours post prandial) and a Glycated Haemoglobin of 5.3% currently.

Discussion

Since diabetes mellitus is known as a life-long condition, the primary objective of diabetes care is prevention of complications. This is ensured through comprehensive care, with glycaemic control being central. The notion that, diabetes mellitus is a chronic disease that cannot be cured, but can only be controlled using lifelong interventions appears to be challenged as evident from some studies.^[1],[2],[3] These studies acknowledged the central role played by calorie restriction,^[1] among other life style measures, alongside pharmacologic intervention.^[2],[3] The benefits of ifestyle intervention and use of oral hypoglycaemic agents in type 2 diabetes prevention and care, cannot be over emphasized.^[4] As essential components of her care, these measures were effective in the patient presented here. Her BMI of 34.7kg/m2, required a good weight control programme. Although such anthropometric pattern is commoner in adults with type 2 Diabetes mellitus, it may also be seen in children and adolescents.^[5] Ordinarily, the possibility of type 1 diabetes will come to mind first, especially with the significant ketonuria, [Table 1]. However, makers of type 1 diabetes were negative, [Table 2]. A challenge here therefore was to classify the diabetes type in this adolescent.

Table 2: Hematologic and immunologic indices

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She had presented in a state of hyperglycaemic emergency with ketonuria, negative markers of autoimmunity, whereas her anthropometric constitution simulated that of type 2 diabetes mellitus. This points to a mixed picture of diabetes mellitus such as reported in ketosis-prone type 2 diabetes mellitus (KP2DM),^[6] a form of atypical diabetes seen increasingly in young black subjects.^[7] A majority of patients with this form of diabetes, present for the first time as an emergency, mainly with unprovoked diabetic ketoacidosis (DKA) while manifesting clinical and metabolic features of type 2 diabetes.^[7] These features were seen in the reported case.

In an attempt to characterise KP2DM, Sobngwi et al^[6] reported a reversible blunting of insulin secretion, with unprovoked hyperglycaemia as seen in our patient, necessitating an initial need for insulin. Insulin administration improved glycaemia, and by extension, insulin response. Interestingly, the blunting of insulin response appears to be the pivot for KP2DM.^[6] So, what then could be the mechanism for this pattern?

Sobngwi et al,^[8] observed a link between G6PD deficiency and hyperglycaemia. Hyperglycaemia can reduce expression of the G6PD-gene and enzyme activity, while G6PD deficiency can promote oxidative stress and impairment of insulin secretion by beta cells,^[8] thus contributing to the observed suppression of insulin response seen in KP2DM. Incidentally, G6PD deficiency is an X-linked disorder with West African male preponderance,^[8] explaining why KP2DM is seen in males. However, the case we present here is a female, leaving the possibility of some other predisposing genetic composition, although G6PD estimates were not done for our patient.

Interestingly, Mauvais-Jarvis et al,^[9] had noted that, a mutation, Arg121Trp, of PAX4(a transcription factor vital for beta-cell development) seen in Japanese subjects with KP2DM was similar to the Arg131Trp of PAX4 found in west African KP2DM subjects. So, PAX4 mutations may be implicated. Improvement in insulin sensitivity after controlling hyperglycaemia represents a reversal process responsible for the varied degree of remission observed in KP2DM.^[6] Considering honey moon phenomenon^[10] in this case is remote, especially as markers of type 1 diabetes-related autoimmunity such as anti-GAD and anti-1A2 were negative [Table 2]. Although remission has been reported in type 1 diabetes,^[2] most of the available reports on remission involved type 2 diabetes,.^[1],[3] Notably, in the previous reports, weight control was very prominent.^[1],[3] Our patient lost about 40% of her weight, potentially contributing to her diabetes reversal. Significant weight loss contributes to diabetes remission through a mechanism involving; a rapid decrease in liver fat with return of normal hepatic insulin sensitivity and return of normal β-cell function.^[11] This results in reversal of acute insulin secretion to non-diabetes levels.^[11] However, not all patients may experience remission. Predictors of remission include; younger age, short diabetes duration, and sustained good glycaemic control especially with significant weight control.^[2],[12] The case reported here was a very recently diagnosed one, in an adolescent, (young age), who had treatment intensification with early and sustained good glycaemic control alongside significant weight loss. Beside this, is the observation that KP2DM is uniquely characterised by remission.^[6]

Conclusions

Diabetes mellitus has shown varied degrees of remission particularly when favourable conditions such as significant weight loss, short diabetes duration, young age, early initiation and intensification of treatment and care. Early diagnosis of diabetes Mellitus as well as early and appropriate initiation and intensification of treatment interventions are highly recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors contribution

The authors had listed contributions;

1. Dr. Onyegbutulem H.C. Corresponding Author;

Conception and design of the research

Interpretation of the data

Drafting the manuscript

Critical revision of the manuscript

Final approval of the manuscript

Overall responsibility

2. Dr. Awogu A.

Interpretation of the data

Critical revision of the manuscript

Final approval of the manuscript

3. Dr. Jibril Abdulahi

Critical revision of the manuscript

Final approval of the manuscript

4. Dr. Henry-Onyegbutulem P.I

Critical revision of the manuscript

Final approval of the manuscript.

References

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