Malnutrition modulated diabetes mellitus in a toddler in resource limited setting: A case report

Introduction

In 1985, World Health Organization had introduced new classification called Malnutrition related diabetes mellitus which later changed to malnutrition modulated diabetes mellitus and then deleted in subsequent classifications. It has distinct clinical features and severity. However, the condition still exists particularly in resource limited countries like Ethiopia. The objective of this case report is to emphasis an unusual case of a severely malnourished, hyperglycemic, and ketone-resistant toddler with a history and signs of severe acute malnutrition, which is resistant to standard therapeutic feeding, later diagnosed as malnutrition-modulated diabetes mellitus.

Presentation of case

A 2-year- and 10-month-old, internally displaced female toddler, brought by her mother with the complaint of excessive urination, eating, and drinking, and associated with significant weight loss of three weeks duration. She was admitted at Semema Primary Hospital, Tigray, northern Ethiopia, with the diagnosis of malnutrition-modulated diabetes mellitus (MMDM). On examination, she had visible severe wasting (bone and skin appearance). Anthropometric measurement indicated underweight, severe wasting (MUAC 7 cm, WFH below −3 WHO Z score), and moderately stunted. She had hyperglycemia (>600 mg/dl) and glycosuria but no ketonuria. Prior to the diagnosis of MMDM, she was repeatedly admitted (4 times) with the diagnosis of complicated severe acute malnutrition (SAM) and treated in inpatient and outpatient therapeutic feeding units according to national guidelines of Ethiopia. However, she was a non-responder. She was started on insulin treatment along with the therapeutic milk after five months of diagnosis of diabetes mellitus was made. Moreover, she had progressive weight gain on insulin therapy. Nonetheless, the demand for insulin to control hyperglycemia remains high (up to 3.6 IU/kg/day) until her discharge and subsequent follow-ups.

Conclusion

There shall be a high index of suspecting malnutrition-modulated diabetes mellitus in resource-limited countries with high prevalence of severe acute malnutrition for early management and better outcome.