Fellow Michigan state university Okemos, Michigan, United States
Introduction : Type 1 diabetes mellites (T1DM) has a very well recognized correlation with autoimmune thyroiditis. However, the occurrence of T1DM alongside Immune Thrombocytopenic Purpura (ITP) is a rare occurrence. In this report, we highlight a unique case of simultaneous diagnosis of both T1DM and ITP during a hospitalization of our patient.
Case(s) Description : Our patient is a 32 year old male with no PMH who presented to the emergency department (ED) with weight loss, polyuria and polydipsia. He additionally reported a two year history of easy bruising with longer than usual healing times especially when playing with his young children. Workup in the ED revealed the patient to be in diabetic ketoacidosis. A complete blood count (CBC) demonstrated a hemoglobin level of 16 g/dL, but notably, platelet counts were alarmingly low at only 9,000 mcL.The patient's severe thrombocytopenia prompted a consultation with the oncology team. After workup revealed ITP, he was provided intravenous immunoglobulin (IVIG) and steroids were deferred due to hyperglycemia. He did have a temporary improvement in his platelet counts but had rebound thrombocytopenia within a few weeks for which he was given additional rounds of IVIG. Further investigations revealed that the patient tested positive for zinc transporter 8, Islet Cell, and glutamic acid decarboxylase antibodies. His blood sugar levels were effectively managed through dietary adjustments and insulin therapy. Though not administered, rituximab an anti CD-20 monoclonal antibody (mAb) was considered by the hematology team as therapy for both his ITP and T1DM.
Discussion : The simultaneous occurrence of ITP and T1DM is an exceedingly rare phenomenon. Often, steroids are the cornerstone therapy for ITP but with new onset diabetes, it would lead to difficult management of a patient's blood sugars. Prior case reports suggest patients with a dual diagnosis respond positively to anti CD-20 mAb therapy for management of both ITP and T1DM. Though patients with T1DM will need continued management with insulin therapy, improved A1C control and decreased insulin dosing may be observed with such therapy through preservation of beta cell function. It is not only important to recognize ITP as an association with T1DM, but consideration should be given early on in diagnosis to anti-CD 20 mAb therapy as a pivotal treatment strategy for managing both conditions effectively.
