Three-Month Retreatment with Cyclosporine A for a Relapse of Type 1 Diabetes Mellitus after 5 Years of Remission

Background: Type I Diabetes mellitus (T1D) results from genetic beta-cell disease that is triggered by autoimmunity. The Case: A 22-year-old man presented with escalating frequency of micturition for 1 week. He was dehydrated and laboratory tests revealed hyperglycemia (21 mmol/L), ketonemia, ketonuria and high Hemoglobin A1C (HA1c) that required resuscitation and insulin therapy. He did not have clinical, laboratory, radiological and serological evidence of recent drug use, chronic illness, autoimmune disease, infections and malignancy. He had similar presentations at the age of 16 years. At that time, he had 2 high insulin antibodies, viz, anti-insulin and anti-GAD yet negative islet cell antibody. Moreover, he had a normal level of C-peptide insulin. Hence, with such positive autoimmune picture and adequate beta-cell function, he was given a trial of Cyclosporine A (CsA) since it is a potent suppressor of T-helper lymphocytes and hence B-lymphocytes. It started at a dose of 100 mg twice daily for 3 months followed by 50 mg twice daily for a total of 1 year. Within 1 month; he did not require insulin-therapy and his insulin antibodies decreased to normal. Up to 5 years of follow-up; he remained in remission with normal HA1c. In his recent relapse of T1D, he did not have high insulin antibodies, as before, yet responded to 3-month re-treatment with CsA 100 mg twice daily and remained euglycemic for 1 year subsequently. Conclusion: T1D can be triggered by autoimmunity that may not be limited to the 3 insulin antibodies yet still amenable to early institution of 3-month CsA-therapy.