Virginia Via Research Day Book 2026

Medical Student Research Case Reports

25 SEQUENTIAL AUTOIMMUNITY: THE DIAGNOSTIC CHALLENGE OF LATENT T1DM MASQUERADING AS T2DM IN AN ADULT PATIENT WITH AUTOIMMUNE HEPATITIS

Harry Trinh, BS, OMS-III; Richard Huneycutt, DO Corresponding author: htrinh@vcom.edu

Prisma Health Tuomey Hospital, Sumter, South Carolina VCOM-Virginia, Blacksburg, Virginia Context: Latent autoimmune diabetes in adults (LADA) is a form of slowly progressive Type 1 diabetes mellitus (T1DM) and is frequently misdiagnosed as Type 2 diabetes mellitus (T2DM), one meta-analysis estimating 8.9% of adults affected globally (Ramu). Co-occurrence of LADA with other non-endocrine autoimmune disorders, like Autoimmune hepatitis (AIH), presents a complex diagnostic trajectory and therapeutic challenge of managing steroid-induced insulin resistance in settings of polyautoimmunity. Report of Case : A 65-year-old Black female, previously diagnosed with T2DM and maintained on Metformin, presented February 2023 with baseline Hemoglobin A1c (HbA1c) 6.4%. In June 2023, she experienced acute nausea, bloating, and marked transaminitis with AST 351 U/L, ALT 646 U/L, and ALP 299 U/L. Initial workup was suggestive of biliary obstruction, but CT and MRCP imaging was unrevealing of biliary ductal dilatation. Subsequent serology revealed sustained transaminitis, hypergammaglobulinemia IgG 2,361 mg/dL, and positive titer for Anti-smooth Muscle Antibody (ASMA) 117 units. A liver biopsy confirmed AIH, revealing moderate inflammatory activity and fibrosis. By July 2023, the patient experienced rapid deterioration of glycemic control, repeat HbA1c 8.4%, necessitating emergency care for severe hyperglycemia.

Recent AIH diagnosis in conjunction with worsening glycemic dysfunction prompted specific diabetes autoantibody testing, revealing a profoundly positive glutamic acid decarboxylase-65 (GAD-65) antibody level 6,905.7 U/mL. This was consistent with new-onset T1DM/LADA, effectively re-diagnosing her diabetes status. Management was complicated by initiation of prednisone for AIH in August 2023, which sharply exacerbated the patient's insulin resistance, HbA1c 9.4%, despite immediate switch to basal-bolus insulin. Azathioprine was introduced as a steroid-sparing agent for prednisone tapering. Over several months, the patient was monitored by multiple specialties for autoimmune management and achieved biochemical remission of AIH in February 2024. Discontinuation of prednisone was accomplished at that time, and AIH was maintained on azathioprine monotherapy. The patient's glycemic control stabilized, achieving a target HbA1c of 6.0% by October 2025. Comments/Methods: Literature review utilized search terms AIH, LADA, and polyautoimmunity to elucidate the importance of effectively managing polyautoimmunity. The prevalence of concomitant AIH and T1DM was estimated to be 3.8% based on a systematic review/meta-analysis of over 36,000 AIH cases (Jensen), and delays glycemic control revealed

enhanced diabetes-related mortality and morbidity rates in those with LADA (Wei). This case demonstrates the critical diagnostic challenge posed by LADA's insidious onset, which mimics T2DM until a second autoimmune trigger necessitates definitive serologic testing. The sequential onset of AIH and LADA reinforces the biological tendency towards polyautoimmunity. Therapeutically, the case highlights the necessity of using steroid-sparing agents to overcome severe corticosteroid-induced insulin resistance in T1DM, allowing for effective concurrent management of both autoimmune conditions without sacrificing metabolic control and sparing the patient of further metabolic sequela. Diagnosis: Final diagnosis was LADA, complicated by development of AIH. This case report highlights the progression of LADA initially misclassified as T2DM, and emphasizes the critical need for aggressive pancreatic autoantibody screening in any established autoimmune patient presenting with new/worsening diabetes to ensure timely insulin initiation and optimal disease management. IRB: None. Patient in case provided written informed consent prior to participation.

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