Progression from Stage 1 to Stage 3 Type 1 Diabetes Characterized by Hypoglycemia

Type 1 diabetes (T1D) development progresses through well-defined stages based on the presence of islet autoantibodies such as insulin autoantibody, glutamic acid decarboxylase autoantibody, tyrosine phosphatase-like protein IA-2 autoantibody, and zinc transporter 8 autoantibody and glycemic status. The presence of multiple islet autoantibodies and normal glucose tolerance is considered stage 1 T1D. Progression to abnormal glucose tolerance, as measured by oral glucose tolerance test or hemoglobin A1c, is considered stage 2, and stage 3 T1D is defined by symptomatic hyperglycemia and the need for insulin replacement therapy. Here, we present a case of a 9-year-old male with rapid progression from stage 1 T1D to stage 3 T1D characterized by persistent, symptomatic hypoglycemia, concurrent with abnormal glucose tolerance. This case demonstrates the paradoxical presence of hypoglycemia and impaired glucose tolerance and suggests that hypoglycemia may be a biomarker of imminent and rapid progression to stage 3 T1D.