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The Scenario:
C. G. is an 18 year old woman who comes to you complaining of weight loss. She has been basically healthy her whole life and apart from some fatigue seems to be in good spirits. She usually weighs about 130 lbs., and is 5 feet 6 inches tall. However, since she started attending college two months ago she suddenly began losing weight. She now weighs 115 lbs. and wonders if something is wrong. She says she has a great appetite although she now eats a lot of soda and junk food. She is thirsty a lot, and say she has to urinate several times a night. She has no burning when she urinates, has had no fever or sweats, has no pain anywhere, and has no other complaints.
Although she has often been concerned about her weight and appearance in the past, she denies being bulimic or abusing laxatives. She also denies any significant drug or alcohol use. Her physical exam is normal.
Questions:
Answer:
The answer to last week's puzzler is diabetes mellitus, type I, also known as juvenile-onset diabetes, or just plain "diabetes".
The important features that distinguish this woman's weight loss from someone else's weight loss begins with noting that she was hungry and thirsty all the time. When someone is losing weight, we normally think of them as eating poorly, as having a decreased appetite. She's eating and drinking more than ever, and can't understand where the calories are going.
Where are they going? They are going into her urine. Normally, your kidneys, whose job it is to continuously filter your blood, hold onto all the sugar in the blood, and let none into the urine. Waste not, want not. But in diabetes, due to a relative lack of the hormone insulin, the blood sugar begins to rise. After a certain threshold is exceeded, it simply spills into the urine. Now, sugar attracts water (as any good maple syrup maker knows). As the sugar pours into the urine it takes lots of water with it -- hence, you're peeing all the time, in large amounts. The soda she was drinking of course was just making things worse. The three "cardinal signs" of diabetes are increased thirst, increased urination, and increased appetite with unexplained weight loss.
As some of our responders noted, her weight loss was occurring for a couple of reasons. First, she was getting dehydrated. Diabetics whose blood sugar is poorly controlled, sometimes show up in the emergency room severely dehydrated, and need many liters, or quarts, of fluid immediately. Second, she was "starving in the midst of plenty" -- she was eating plenty of calories, but in the absence of insulin, the sugar can not get into the tissues where it is needed, so the body's cells are literally starving. The body responds by breaking down fat and protein for energy, so there is real loss of lean body mass as well.
The one best diagnostic test is a blood sugar. Normally this should be between about 60 and 120. In this woman, it would not be surprising to find blood sugars of 4 - 600. In extreme cases, sugars over 1000 are found. The urine could also be tested for sugar, and would likely be positive in this case. However, the urine test is not as good, since the amount of sugar in the urine does not correlate with what is happening in the blood stream, and because in borderline cases, the blood sugar may be elevated before anything appears in the urine.
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