Stress-Induced Diabetic Ketoacidosis Due to Transient Beta-Cell Stunning in Youth with Type 2 Diabetes Mellitus

Dear Editor, We read with great interest the case report titled “Stress-induced diabetic ketoacidosis due to transient beta-cell stunning in a youth with type 2 diabetes mellitus” by Sriraam et al.[1] The authors’ suggestion to estimate all three pancreatic autoantibodies to differentiate type 1 diabetes mellitus (T1DM) from other forms is valuable. However, we would like to highlight that the prevalence and significance of pancreatic autoantibodies vary considerably based on age, disease duration, and ethnic origin of the patients. In Caucasians, the presence of one or more islet-cell antibodies is observed in over 90% of patients at the onset of T1DM, and idiopathic diabetes is relatively uncommon.[2] However, studies from Asian countries report a significantly lower prevalence of these autoantibodies. For instance, a high frequency of pancreatic antibody-negative or type 1B (idiopathic) diabetes (30%) has been noted in Indian children when antibodies against all four major islet antigens are considered.[3] Idiopathic T1DM is a heterogeneous entity with numerous variants described in the literature. For example, a fulminant form of T1DM has been described in Japan, China, and Korea. The involvement of viral infection has been suggested as the pathogenesis of fulminant T1DM. It has a sudden onset with ketosis or ketoacidosis within a week after the onset of hyperglycemic symptoms, with flu-like symptoms observed in most patients.[4] Winter et al.[5] described idiopathic T1DM in young Black Americans with obesity and acanthosis nigricans, presenting with severe hyperglycemia and diabetic ketoacidosis. However, studies from India have shown that patients with idiopathic T1DM had similar clinical features to antibody-positive subjects.[3,6] These variations underscore the importance of considering ethnic and regional differences when interpreting autoantibody results in diabetic patients. In regions with a lower prevalence of autoantibodies, negative tests may not necessarily exclude T1DM and could suggest a different pathophysiological mechanism or subtype of diabetes, such as type 1B. Therefore, while estimating pancreatic autoantibodies is useful, it is essential to contextualize these findings within the demographic and regional background of the patient population. This approach ensures a more accurate diagnosis and appropriate management of diabetes. Acknowledgement Nil. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.