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别误诊1.5型糖尿病

2017-04-19 辛永宁 住院医生日记

今天从骨科转来一名28岁体型偏瘦的男子,因为受外伤后,在骨科治疗期间发现2 型糖尿病而转入我科。其否认有糖尿病史,否认有家族史。转入时患者空腹血糖10.5mmol/L。我作为主治医师分析,结合该患者的发病年龄,体型偏瘦,我认为该患者不应当诊断为2 型糖尿病,诊断为1型较为恰当。但是检查患者的血空腹C 肽<0.2mmol/L 和胰高血糖素刺激后(或餐后2小时)<0.42 mmol/L,说明仍有部分胰


今天从骨科转来一名28岁体型偏瘦的男子,因为受外伤后,在骨科治疗期间发现2 型糖尿病而转入我科。其否认有糖尿病史,否认有家族史。转入时患者空腹血糖10.5mmol/L。我作为主治医师分析,结合该患者的发病年龄,体型偏瘦,我认为该患者不应当诊断为2 型糖尿病诊断为1型较为恰当。但是检查患者的血空腹C 肽<0.2mmol/L 和胰高血糖素刺激后(或餐后2小时)<0.42 mmol/L,说明仍有部分胰岛功能是正常的,所以诊断为1 型也不恰当。主任查房提示应当诊断为1.5型糖尿病,所以联合检测谷氨酸脱羧酶抗体(GADAb)、胰岛细胞抗体(ICA)及胰岛素自身抗体(I AA)。等检查结果出来:均为阳性,诊断为1.5型糖尿病。

心得体会

1.5型糖尿病,又称成人迟发性自身免疫糖尿病(LADA),在我国占糖尿病发病率的1%,容易被误诊、漏诊,从而导致治疗方法不正确或者不及时,加重病情。近年,随着实验室水平的提高及各级医生的重视,确诊的病例越来越多。

目前认为成人迟发性自身免疫糖尿病其实质是由于免疫破坏胰岛B 细胞引起的胰岛素缺乏性糖尿病。特点是相对于1型来讲,由于其胰岛细胞破坏缓慢而延至25~34岁左右才发病;相对于2 型糖尿病,这类病人比较消瘦或者低体重,体重指数:BMI <21kg/m 2。一般发病半年后自发酮症酸中毒,磺脲类口服降糖药继发失效,血空腹C 肽<0.3mmol/L 和(或)胰高血糖素刺激后(或餐后2小时)<0.6mmol/L。临床结合GAD Ab、I CA 及I AA 联合检测,排除线粒体基因突变糖尿病及年轻的成年发病型糖尿病(MODY)的情况下,可以确诊为LADA。这种糖尿病多发生于应激情况下,如严重感染、创伤后被迅速暴露出来的。

认识LADA 的意义在于:一旦确定应即刻应用胰岛素,加用免疫抑制剂,如小剂量的环孢素A 或者雷公藤总苷(雷公藤多苷)片,目的在于阻止自身免疫介导的胰岛B 细胞的损伤,促进胰岛修复,延缓胰岛素依赖阶段的出现,达到良好的代谢控制,减少慢性并发症。否则若再用刺激胰岛素分泌的磺脲类药物如格列齐特(达美康)、格列吡嗪(美吡达)等会使可能残剩的部分胰岛细胞遭到彻底破坏,造成更严重的损害,所以勿用磺脲类降糖药治疗LADA。

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    2017-04-20 虈亣靌

    不错的方式,努力学习,刻苦专研,不断总结出来新经验。

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=189132, encodeId=f2d718913236, content=不错的方式,努力学习,刻苦专研,不断总结出来新经验。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Thu Apr 20 20:32:20 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189015, encodeId=0c1418901501, content=学习了分享了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Thu Apr 20 08:54:47 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188993, encodeId=d4a418899344, content=签到学习了很多。, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/A3E53E62691178E2F18D7B999FD22131/100, createdBy=f44d2003846, createdName=Chongyang Zhang, createdTime=Thu Apr 20 07:35:17 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188949, encodeId=52df188949f8, content=很好的内容学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5K3r6Ir8EADbw8kut6NgpfYKrksLd7rsf9GSZGCUZkpHosu8Jsibzk64KSuO8dFfOW7J5kW4bjib4eI/0, createdBy=d0201619051, createdName=吴颖, createdTime=Thu Apr 20 01:14:02 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188924, encodeId=64f9188924cf, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Apr 20 00:13:49 CST 2017, time=2017-04-20, status=1, ipAttribution=)]
    2017-04-20 dhzzm

    学习了分享了

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=189132, encodeId=f2d718913236, content=不错的方式,努力学习,刻苦专研,不断总结出来新经验。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Thu Apr 20 20:32:20 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189015, encodeId=0c1418901501, content=学习了分享了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Thu Apr 20 08:54:47 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188993, encodeId=d4a418899344, content=签到学习了很多。, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/A3E53E62691178E2F18D7B999FD22131/100, createdBy=f44d2003846, createdName=Chongyang Zhang, createdTime=Thu Apr 20 07:35:17 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188949, encodeId=52df188949f8, content=很好的内容学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5K3r6Ir8EADbw8kut6NgpfYKrksLd7rsf9GSZGCUZkpHosu8Jsibzk64KSuO8dFfOW7J5kW4bjib4eI/0, createdBy=d0201619051, createdName=吴颖, createdTime=Thu Apr 20 01:14:02 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188924, encodeId=64f9188924cf, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Apr 20 00:13:49 CST 2017, time=2017-04-20, status=1, ipAttribution=)]
    2017-04-20 Chongyang Zhang

    签到学习了很多。

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=189132, encodeId=f2d718913236, content=不错的方式,努力学习,刻苦专研,不断总结出来新经验。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zMoyicyo6ia9f4IuLQAwZoxD6Hx4ibd5CMcOCYhStY6oDibbKK6O2X8iaicldO5ib8j1iapOIobIKCGiczU2A/0, createdBy=56251941490, createdName=虈亣靌, createdTime=Thu Apr 20 20:32:20 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=189015, encodeId=0c1418901501, content=学习了分享了, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Thu Apr 20 08:54:47 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188993, encodeId=d4a418899344, content=签到学习了很多。, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/A3E53E62691178E2F18D7B999FD22131/100, createdBy=f44d2003846, createdName=Chongyang Zhang, createdTime=Thu Apr 20 07:35:17 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188949, encodeId=52df188949f8, content=很好的内容学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5K3r6Ir8EADbw8kut6NgpfYKrksLd7rsf9GSZGCUZkpHosu8Jsibzk64KSuO8dFfOW7J5kW4bjib4eI/0, createdBy=d0201619051, createdName=吴颖, createdTime=Thu Apr 20 01:14:02 CST 2017, time=2017-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=188924, encodeId=64f9188924cf, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Apr 20 00:13:49 CST 2017, time=2017-04-20, status=1, ipAttribution=)]
    2017-04-20 吴颖

    很好的内容学习了

    0

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    2017-04-20 飛歌

    学习了很有用

    0

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