CMAJ • August 16, 2005; 173 (4). doi:10.1503/cmaj.1050095.
© 2005 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters
Correspondance

Are children with type 1 diabetes immunocompromised?

Shareef Mustapha*, Elizabeth Sellers{dagger} and Heather Dean{ddagger}

PGY-1;* Assistant Professor;{dagger} Professor, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Man.{ddagger}

In their clinical report of a 4-year-old child with leukemia and an enlarging arm lesion that proved to have been caused by an opportunistic fungus, Ahmed Mater and associates1 state that "[these i]nfections generally occur in immunocompromised patients with conditions such as neutropenia, diabetes or hematologic malignant disease."1 This statement implies that all patients with type 1 or type 2 diabetes mellitus are immunocompromised. Our interest is children (up to 18 years of age) with type 1 diabetes, and we challenge the accuracy of the statement in this context.

Mater and associates1 cite 2 papers2,3 that listed "diabetes," specifically diabetes complicated by ketoacidosis, as a risk factor for opportunistic infections. However, those articles did not provide evidence to support this claim in children with type 1 diabetes. Is there any evidence to show increased rates of infection or prolonged recovery from infection in children with type 1 diabetes? In-vitro data have demonstrated impaired immune function due to hyperglycemia and/or hypoinsulinemia in association with type 1 diabetes.4,5 However, those studies did not show that the differences in cell-mediated and humoral immune function translate into significant morbidity or mortality in the clinical setting. In fact, the humoral response to influenza vaccine in patients with type 1 diabetes is no different from that of controls with respect to protection rates.6 The incidence of candidal infection is greater among patients with type 1 diabetes, but the reason for this is unclear.7,8 It may be due to a genetic polymorphism in the gene encoding ß-defensin 1.8 However, there is no evidence that this genetic difference leads to an immunocompromised state allowing invasive fungal disease to occur. There have been case reports of patients with type 1 diabetes and diabetic ketoacidosis in whom severe opportunistic infections have developed.9 The increased susceptibility may be attributed to the short-term acidic environment of diabetic ketoacidosis, which is ideal for certain opportunistic pathogens.

In summary, there is insufficient evidence to conclude that children with type 1 diabetes mellitus are immunocompromised. The evidence indicates that an immunocompromised state occurs only in the context of poor glycemic control with severe complications such as diabetic ketoacidosis or in adults with vasculopathy and peripheral neuropathy. Fortunately, with modern standards of care and education of families to manage intercurrent illness in their children with type 1 diabetes mellitus, hospital admission for diabetic ketoacidosis is now rare.

References

  1. Mater A, Al-Sulaiti G, Johnston DL, Slinger R. A 4-year-old child with leukemia and an enlarging arm lesion. CMAJ 2005;172(3):332.[Free Full Text]
  2. Prabhu RM, Patel R. Mucormycosis and entomophthoramycosis:a review of the clinical manifestations, diagnosis and treatment. Clin Microbiol Infect 2004;10(Suppl 1):31-47.
  3. Boyd AS, Wiser B, Sams HH, King LE. Gangrenous cutaneous mucormycosis in a child with a solid organ transplant: a case report and review of the literature. Pediatr Dermatol 2003;20:411-5.[CrossRef][Medline]
  4. Calvet H, Yoshikawa TT. Infections in diabetes. Infect Dis Clin North Am 2001;15:407-21.[CrossRef][Medline]
  5. Moutschen MP, Scheen AJ, Lefebvre PJ. Impaired immune responses in diabetes mellitus: analysis of the factors and mechanisms involved. Relevance to the increased susceptibility of diabetic patients to specific infections. Diabete Metab 1992;18:187-201.[Medline]
  6. Diepersloot RJA, Bouter KP, Beyer WEP, Hoekstra JBL, Masurel N. Humoral immune response and delayed type hypersensitivity to influenza vaccine in patients with diabetes mellitus. Diabetologia 1987;30:397-401.[CrossRef][Medline]
  7. Willis AM, Coulter WA, Fulton CR, Hayes JR, Bell PM, Lamey PJ. Oral candidal carriage and infection in insulin-treated diabetic patients. Diabet Med 1999;16:675-9.[CrossRef][Medline]
  8. Jurevic RJ, Bai M, Chadwick RB, White TC, Dale BA. Single-nucleotide polymorphisms (SNPs) in human ß-defensin 1: high-throughput SNP assays and association with Candida carriage in type I diabetics and nondiabetic controls. J Clin Microbiol 2003;41:90-6.[Abstract/Free Full Text]
  9. Moye J, Rosenbloom AL, Silverstein J. Clinical predictors of mucormycosis in children with type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2002;15:1001-4.[Medline]




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