2253-PUB: A Rare Case of Fulminant Type 1 Diabetes Postpartum

Amongst women with gestational diabetes (GDM), the incidence of type 1 diabetes (T1DM) was 3.4% at 9 months post-partum and 6.6% at 2 years post-partum in one prospective study. Higher number of autoantibodies (Abs) during pregnancy is associated with a higher risk of T1DM. In rare cases, women with GDM can develop antibody-negative T1DM post-partum. The presentation of fulminant T1DM defined as rapid onset ketoacidosis, undetectable C-peptide, A1C<8.5%, elevated pancreatic enzymes and often negative antibodies has only rarely been reported in the post-partum period and predominantly in individuals of Japanese descent. In our case, a 34-year-old woman of Indian descent presented for GDM which required low dose Detemir 6 units nightly. She had an uncomplicated delivery and stopped insulin. On post-partum day 8 she was hospitalized for 1 day of non-specific malaise symptoms and was incidentally found to have elevated lipase 398 U/L, serum glucose 93 mg/dL and mildly bulky pancreas by ultrasound imaging. Initially she clinically improved, but on post-partum day 15 she developed symptoms of fatigue, polyuria, polydipsia, and weight loss which progressed to vomiting, tachycardia and tachypnea. She was readmitted on post-partum day 19 with glucose 482 mg/dL, arterial pH 6.95, anion gap 34, and moderate ketones consistent with severe Diabetic Ketoacidosis. Hemoglobin A1C was 6% and lipase was normal. New onset T1DM was diagnosed based on undetectable C-peptide, though GAD and ICA Abs were negative. She was treated with an insulin infusion and later transitioned to a basal-bolus subcutaneous insulin regimen. Repeat labs at 12 months post-partum confirmed persistent undetectable C-peptide and negative Abs. We present a unique case of a woman of Indian descent with GDM found to have fulminant T1DM in the early post-partum period. To our knowledge, this is the first case of fulminant diabetes post-partum reported in a patient of Indian ethnicity. Our case highlights the importance of consideration of this rare diagnosis in diverse populations.