Type 1 Diabetes Often Misdiagnosed in Adults and Children

Type 1 diabetes is frequently misdiagnosed in both children and adults, and misdiagnosis increases the risk for diabetic ketoacidosis (DKA) in children, new research finds.

Results of a survey of 2526 participants recruited from the T1D Exchange clinic and online communities were published in the July 2019 issue of Clinical Diabetes by Cynthia E. Muñoz, PhD, of the University of Southern California, Los Angeles, and colleagues.

Overall, the survey revealed 25% of respondents themselves or their children with type 1 diabetes had been initially misdiagnosed and that misdiagnosis was associated with an 18% increased risk for DKA compared with those in whom the type 1 diabetes was recognized and treated with insulin immediately.

The most common misdiagnoses were influenza or other viral infections in children and type 2 diabetes in adults. Thus, Muñoz and colleagues write, "adult providers should consider type 1 diabetes when diagnosing type 2 diabetes, and pediatric providers should rule out type 1 diabetes when a patient reports nonspecific viral symptoms."

In contrast to the more common lifestyle-associated type 2 diabetes, type 1 diabetes is an autoimmune disease with an estimated incidence of 21.7/100,000 youths in the United States. There are no reliable estimates for the incidence of type 1 diabetes in adults, but recent data suggest that the onset is just as common after age 30 years as it is in younger people.

The authors suggest it might be possible for future electronic health record functionalities and interoperability between institutions to offer emergency and primary care clinicians decision support to increase the likelihood of identifying new-onset type 1 diabetes.

"For example, weight loss in a growing child could trigger alerts suggesting inexpensive glucose testing, and a diagnosis of type 2 diabetes in a nonobese adult could similarly offer the option to check diabetes antibodies," write the authors.

Misdiagnosis Common but Differs by Age

The online survey respondents were recruited through the T1D Exchange clinic registry and the T1D Exchange online patient community (www.myGlu.org). The T1D Exchange is a network that connects various stakeholders and collects real-world clinical data to inform type 1 diabetes research, clinical care, and product development.

Of the 2526 adult respondents, 78% had type 1 diabetes themselves and 22% were parents or guardians of children with the condition.

The most common symptoms at presentation of type 1 diabetes in both adults and children were excessive thirst (84.3% and 90.0%, respectively), fatigue (77.9% and 73.2%), frequent urination (77.0% and 84.6%), and weight loss (73.9% and 71.4%).

However, other symptoms differed by age. Adults were more likely than children to report blurred vision (49.3% vs 30.0%), vaginal yeast infections (21.3% vs 7.4%), tingling in the hands and feet (12.4% vs 3.7%), and slow healing of sores (11.8% and 5.9%).

Children, on the other hand, more often experienced stomach pain (21.6% vs 11.1%), nausea/vomiting (31.9% vs 17.5%), and flulike symptoms (29.9% vs 17.4%) compared with adults.

Initial misdiagnosis was reported in 24% of the full cohort. The diagnosis of type 1 diabetes was missed in 38.6% of adults and 16% of children (P < .001).

Among the 856 respondents with diagnosis of type 1 diabetes in adulthood, the most common initial misdiagnosis was type 2 diabetes in 76.8%; flu or other viral infection accounted for just 8.6% of misdiagnoses. In contrast, of the 1670 children, flu/viral infection was the initial misdiagnosis in 53.7% and strep/bacterial infection in 19.1%.

DKA at Diagnosis More Likely in Misdiagnosed Children

Overall, 66.1% of the full cohort were hospitalized at diagnosis and 40.9% experienced DKA. Children were more likely than adults to experience DKA (48.0% vs 28.1%; P < .001) and require intravenous fluids (92.9% vs 78.4%; P < .001).

While those with a missed diagnosis were 17.6% more likely to progress to DKA compared with those correctly diagnosed (45.2% vs 38.4%; P < .05), this relationship was only significant in children (68% with a missed diagnosis vs 42.8% with a correct initial diagnosis developed DKA; P < 0.001). There was no difference in DKA rates among adults with correct versus incorrect diagnoses.

Overall, 21% of the cohort were admitted to the intensive care unit, and the majority of those were in DKA (83.4%). Of those admitted to ICU, 25.0% were unconscious.

Muñoz has reported no relevant financial relationships.

Clin Diabetes. 2019;37:276-281. Abstract

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