Case history
Case history
A 10-year-old African-American girl is seen by her primary care pediatrician during a routine well-child check. She is noted to be tall for her age (height >95th percentile) and has obesity (body mass index >95%). On physical exam, she is found to have acanthosis nigricans on her neck and axilla and has a vaginal yeast infection. She is noted to be Tanner stage 3 for breast and pubic hair development. Urinalysis reveals glucose >1000 mg/dL with negative protein and ketones. A random blood glucose, obtained because of the glycosuria, is 349 mg/dL. Family history reveals both parents have obesity, and the mother had gestational diabetes during her last two pregnancies. Maternal grandparents have type 2 diabetes mellitus (T2DM), as do multiple maternal and paternal aunts and uncles. The maternal grandfather had a myocardial infarction at age 48 and has hypertension and hypercholesterolemia. The child's father had coronary bypass surgery at age 42.
Other presentations
Although most children have overweight (body mass index [BMI] 85th to 95th percentile for age and sex) or obesity (BMI >95th percentile) at diagnosis, some will not have overweight.[3] Diabetic ketoacidosis may be present in 5% to 25% of children with T2DM at presentation.[4]
The majority of children with T2DM are diagnosed over the age of 10 years, but those in high-risk populations (i.e., predisposing racial/ethnic background, obesity, and strong family history) can present as early as age 4 years.[5] Puberty is thought to worsen preexisting insulin resistance in children with obesity, and most children are in middle-to-late puberty at the time of diagnosis.
A history of T2DM in a first- or second-degree relative is present in 74% to 100% of children.[5]
Acanthosis nigricans is common at presentation, as are sleep apnea, polycystic ovarian syndrome, hypertension, metabolic dysfunction-associated steatotic liver disease (formerly called nonalcoholic fatty liver disease), and dyslipidemia, all of which are considered comorbidities of obesity-related T2DM.[6]
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