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November 13, 2005

Diagnosis and Symptoms, Hypoglycemia

Question from Plainwell, Michigan, USA:

My son has documented ketotic hypoglycemia. In the last few weeks, he has complained of intense thirst, has been urinating often, and has been eating non stop. Although he has grown four inches, he weighs only two pounds more than he did a year ago. Because I had a glucose monitor for the hypoglycemia, I checked his blood sugar. The first check, right after swim practice, was 79 mg/dl [4.4 mmol/L], so I didn't worry. Last night, however, he began crying because he was so thirsty and he couldn't drink enough to stop it. His blood sugar was over 200 mg/dl [11.1 mmol/L]. I called the doctor and when we were in the office, it was 71 mg/dl [3.9 mmol/L] on my meter. We left the office and got something to eat. One hour after the meal, he was 99 mg/dl [5.5 mmol/L]. Two hours later, he was complaining of leg cramps, arm cramps and a stomach ache. This time, his blood sugar was 537 mg/dl [29.8 mmol/L]! After swim practice again, he was back to 100 mg/dl [5.6 mmol/L]. The doctor did a hemoglobin test today to check his levels over the last few months. I checked the control on my meter and it was fine. I also checked my own blood sugar and got consistent readings in the 90s mg/dl [5.0 to 5.5 mmol/L]. Is it unusual to get such scattered readings with the onset of the disease? What if the doctor says everything is normal? Why would it be over 500 mg/dl [27.8 mmol/L]? I have a brand new One Touch Ultra monitor. Should I insist that they retest him? They want me to keep a log on the meter for a few days including fasting sugars. I also have to collect morning urine, because what they had today was not concentrated. There was no sugar or ketones.

Answer:

Your story is certainly interesting and somewhat compelling. Please see Classification and Diagnosis of Diabetes.

At present, based on what you’ve written, I do not think your son has diabetes mellitus but, again, the story is atypical. While you have double-checked your meter and the codes, and the control solution, etc, have you double-checked your blood checking technique by assuring that his finger is CLEAN and DRY before getting the blood droplet?

The test you referred to as the “hemoglobin test” was probably really the “Hemoglobin A1c” test, which can give an estimate of what the glucose levels have been over the past several, several weeks. So, this test can be normal even in someone with diabetes (very recent onset or in fabulous control); it is NOT used to establish a diagnosis of diabetes.

Is there a family history of diabetes, especially type 1 diabetes, or other autoimmune disease? If diabetes were really suspected, this might be one of those rarer time that a properly performed Oral Glucose Tolerance Test (OGTT) might be warranted. Pancreatic antibody testing for type 1 diabetes might be something I would hold off.

Typically, in diabetes, there would not be glucose in the urine until the blood glucose was maintained above 180 mg/dL [10.0 mmol/L] for a bit.

Many, many other conditions can lead to increased urination and increased thirst. Substantially increased thirst associated with NON-concentrated urine as you allude to brings to mind a different hormonal condition, confusingly called “diabetes insipidus” which has NOTHING to do with glucose. What’s your son doing at night? Is he awakening to drink and/or urinate then, too? Is he drinking from “odd” sources? Is he wetting the bed? Is he preferring particular fluids to drink?

Please continue to meet with your pediatrician who may want to refer you to or consult with a pediatric endocrinologist when the initial screen studies are back.

Please let us know what you learn.

DS