Recurrent Hypoglycemia as an Unusual Finding in Pediatric New-Onset Type 1 Diabetes: A Case Report and Review of the Literature

Introduction: Recurrent hypoglycemia occurring prior to the initiation of insulin therapy is an uncommon finding at the onset of pediatric type 1 diabetes mellitus (T1D). Aim: The aim of this study was to describe an unusual presentation of T1D onset characterized by recurrent hypoglycemia in a pediatric patient and to provide an updated review of the literature on hypoglycemic episodes occurring before insulin initiation in children with new-onset T1D. Case report: We present the case of a child who exhibited recurrent fasting hypoglycemia and postprandial hyperglycemia at the onset of T1D. Clinical findings also included persistently elevated glucagon levels (66–93 pmol/L; normal values [n.v.] 3–60); markedly elevated glycated hemoglobin (98 mmol/moL); low C-peptide levels (0.05 nmol/L); and a slight positivity for antibodies to glutamic acid decarboxylase (38.3 KUI/L; n.v. < 10). Review of the literature: A narrative review of the literature was conducted using the PubMed (MEDLINE) database to identify studies reporting hypoglycemia at the onset of T1D in pediatric patients prior to insulin initiation. The search included combinations of the terms hypoglycemia, new-onset, type 1 diabetes, child, and adolescent, with an exclusion of insulin-treated cases. We also explore potential pathogenetic mechanisms underlying this unusual presentation, including alpha-cell acute damage or dysregulation and loss of intra-islet paracrine signaling. Conclusions: Among individuals with T1D onset, episodes of recurrent hypoglycemia before the initiation of insulin therapy have been reported in a few studies. The presented case expands the clinical spectrum of early T1D and suggests that early alpha-cell dysfunction may contribute to atypical glycemic patterns during disease onset.