Diabetes mellitus
Clinical picture and diagnosis.
Diabetes mellitus (DM) is the most common endocrine disease. DM is a syndrome of the
chronic hyperglycemia, caused by absolute or relative insulin secretory deficiency. And chronic
hyperglycemia is the trigger of all late (long-term) complications: microvascular, macrovascular
and neurological once. More over, patients suffered of DM have inheritance immunodeficiency
that is why these patients have increased propensity to infections.
The diagnosis of symptomatic DM is not difficult, (when a patient has got thirst, polyuria
and hyperglycemia the diagnosis is unequivocal). There are several criteria for diagnosis of DM
in nonpregnant individuals (WHO, 1999):
1. Symptoms of severe insulin secretory deficiency, such as polyuria, polydipsia and
rapid weight loss together with random plasma glucose concentration > 200 mg/dL [11.1
mmol/L] (term “random” means independent from the time of last having meal).
2. Fasting plasma glucose concentration ≥ 126 mg/dL [7.0 mmol/L] on more than
one occasion. Capillary whole-blood values are lower in the basal state and are considered
abnormal if they exceed 110 mg/dL [6.1 mmol/L].
3. Abnormal results of oral glucose-tolerance test (hyperglycemia ≥ 200 mg/dL [11.1
mmol/L] in 2 hour after 75-g glucose dose ingestion).
The problem arises with the patients without the clinical symptoms. They are considered
to be potential diabetic but have a normal fasting glucose concentration in plasma. In this case
we should recommend them to investigate the glucose blood level in oral glucose tolerance test.
The glucose-tolerance test should be standardized as follows:
1. The test should be performed after an overnight fast in morning hours (plasma
glucose responses to oral glucose higher in the afternoon).
2. The test should be preceded at least for 3 days by habitual diet and physical
activity.
3. Only two blood samples need to be collected: the first at time zero and the second
at 2 hours.
4. Drugs that alter glucose tolerance (benzothiadiazines, salicylates, corticosteroids,
nicotinic acid, oral contraceptive agents, as well as insulin and oral hypoglycemic agents etc.)
should be discontinued, if possible.
5. A patient has not to have overt or occult infections, other current diseases (stress
impair glucose tolerance).
Basal fasting glycemia is measured firstly. As soon as first blood sample is collected,
carbohydrate load is performed. Adult patients ingest 75 g of glucose dissolved into 300ml of
water. The glucose solution should be ingest in 5 minutes. Prandial(after meal) glycemia is
estimated at 2 hours.
You may have the following results: (see Table 1).
Table 1
Oral glucose-tolerance test results interpretation (WHO, 1999).
Glucose concentration, mg/dL [mmol/L]
Conclusion Characteristics
Venous plasma Capillary whole-blood
Fasting ≥126 [7.0] ≥110 [6.1]
Diabetes mellitus
at 2 hours ≥200 [11.1] ≥200 [11.1]
Fasting <126 [7.0] <110 [6.1]
Impaired glucose
140-199 140-199
tolerance at 2 hours
[7.8-11.0] [7.8-11.0]
Impaired fasting 100-109 110-125
Fasting
glycemia [5.6-6.0] [6.1-6.9]
1
, at 2 hours <140 [7.8] <140 [7.8]
Fasting <110 [6.1] <100 [5.6]
Normal
at 2 hours <140 [7.8] <140 [7.8]
Endocrinologists mainly have deal with Type 1 and Type 2 DM. Other Specific Types of
DM are rare. Their diagnosis is commonly based on genetic analysis and immunologic tests.
Gestational diabetes is defined as the development of altered glucose metabolism during
pregnancy in a woman with no previous history of disease. Glucose metabolism derangements
are transient; they disappear after the pregnancy is over.
Gestational diabetes diagnosis is based on fasting plasma glucose concentrations and
glycemia after ingestion of 100-g glucose dose. Two ore more of the following concentrations
shall be exceeded for the diagnosis:
Fasting glycemia ≥ 105 mg/dL [5.8 mmol/L]
In 1 hour ≥ 190 mg/dL [10.6 mmol/L]
In 2 hour ≥ 165 mg/dL [9.2 mmol/L]
In 3 hour ≥ 145 mg/dL [8.1 mmol/L]
Clinical picture of DM
Hyperglycemia is the most universal symptom of DM. But there is a lot of other clinical
displays of DM. All symptoms of DM can be categorized in several main syndromes.
1. Syndrome of severe insulin secretory deficiency.
Pathogenesis of this syndrome is as follows: insulin dependent tissues (muscle, fat and
liver) can’t utilize glucose without insulin. Insulin as a conductor of glucose into tissues is
absent. That is why all the glucose rests in the blood and a result energetic deficiency is
developed. It stimulates secretion of contrinsulin hormones to activate glyconeogenesis and cope
with energetic deficiency. Glycemia blood level increases more and more and results in
hyperosmolality. It causes such symptoms as polyuria and polydipsia. Energetic deficiency and
metabolic changes lead to weight loss and polyphagia.
2. Paradiabetic Syndrome (Syndrome of small signs).
1. Skin and mucous membrane affection
Relapsed furunculosis, acne, eczema etc.;
Genital and skin itching;
Slow wound recovering.
2. Dental and oral cavity pathology
Paradontosis;
Relapsed stomatitis and gingivitis;
Active dental caries.
3. Eye pathology
Cataract.
4. Reproductive system disfunction
Erectile disfunction;
Menstrual disorders;
Loss of libido.
5. CNS disfunction
Memory impairment
Poor concentration and intellectual fatigability
2
Clinical picture and diagnosis.
Diabetes mellitus (DM) is the most common endocrine disease. DM is a syndrome of the
chronic hyperglycemia, caused by absolute or relative insulin secretory deficiency. And chronic
hyperglycemia is the trigger of all late (long-term) complications: microvascular, macrovascular
and neurological once. More over, patients suffered of DM have inheritance immunodeficiency
that is why these patients have increased propensity to infections.
The diagnosis of symptomatic DM is not difficult, (when a patient has got thirst, polyuria
and hyperglycemia the diagnosis is unequivocal). There are several criteria for diagnosis of DM
in nonpregnant individuals (WHO, 1999):
1. Symptoms of severe insulin secretory deficiency, such as polyuria, polydipsia and
rapid weight loss together with random plasma glucose concentration > 200 mg/dL [11.1
mmol/L] (term “random” means independent from the time of last having meal).
2. Fasting plasma glucose concentration ≥ 126 mg/dL [7.0 mmol/L] on more than
one occasion. Capillary whole-blood values are lower in the basal state and are considered
abnormal if they exceed 110 mg/dL [6.1 mmol/L].
3. Abnormal results of oral glucose-tolerance test (hyperglycemia ≥ 200 mg/dL [11.1
mmol/L] in 2 hour after 75-g glucose dose ingestion).
The problem arises with the patients without the clinical symptoms. They are considered
to be potential diabetic but have a normal fasting glucose concentration in plasma. In this case
we should recommend them to investigate the glucose blood level in oral glucose tolerance test.
The glucose-tolerance test should be standardized as follows:
1. The test should be performed after an overnight fast in morning hours (plasma
glucose responses to oral glucose higher in the afternoon).
2. The test should be preceded at least for 3 days by habitual diet and physical
activity.
3. Only two blood samples need to be collected: the first at time zero and the second
at 2 hours.
4. Drugs that alter glucose tolerance (benzothiadiazines, salicylates, corticosteroids,
nicotinic acid, oral contraceptive agents, as well as insulin and oral hypoglycemic agents etc.)
should be discontinued, if possible.
5. A patient has not to have overt or occult infections, other current diseases (stress
impair glucose tolerance).
Basal fasting glycemia is measured firstly. As soon as first blood sample is collected,
carbohydrate load is performed. Adult patients ingest 75 g of glucose dissolved into 300ml of
water. The glucose solution should be ingest in 5 minutes. Prandial(after meal) glycemia is
estimated at 2 hours.
You may have the following results: (see Table 1).
Table 1
Oral glucose-tolerance test results interpretation (WHO, 1999).
Glucose concentration, mg/dL [mmol/L]
Conclusion Characteristics
Venous plasma Capillary whole-blood
Fasting ≥126 [7.0] ≥110 [6.1]
Diabetes mellitus
at 2 hours ≥200 [11.1] ≥200 [11.1]
Fasting <126 [7.0] <110 [6.1]
Impaired glucose
140-199 140-199
tolerance at 2 hours
[7.8-11.0] [7.8-11.0]
Impaired fasting 100-109 110-125
Fasting
glycemia [5.6-6.0] [6.1-6.9]
1
, at 2 hours <140 [7.8] <140 [7.8]
Fasting <110 [6.1] <100 [5.6]
Normal
at 2 hours <140 [7.8] <140 [7.8]
Endocrinologists mainly have deal with Type 1 and Type 2 DM. Other Specific Types of
DM are rare. Their diagnosis is commonly based on genetic analysis and immunologic tests.
Gestational diabetes is defined as the development of altered glucose metabolism during
pregnancy in a woman with no previous history of disease. Glucose metabolism derangements
are transient; they disappear after the pregnancy is over.
Gestational diabetes diagnosis is based on fasting plasma glucose concentrations and
glycemia after ingestion of 100-g glucose dose. Two ore more of the following concentrations
shall be exceeded for the diagnosis:
Fasting glycemia ≥ 105 mg/dL [5.8 mmol/L]
In 1 hour ≥ 190 mg/dL [10.6 mmol/L]
In 2 hour ≥ 165 mg/dL [9.2 mmol/L]
In 3 hour ≥ 145 mg/dL [8.1 mmol/L]
Clinical picture of DM
Hyperglycemia is the most universal symptom of DM. But there is a lot of other clinical
displays of DM. All symptoms of DM can be categorized in several main syndromes.
1. Syndrome of severe insulin secretory deficiency.
Pathogenesis of this syndrome is as follows: insulin dependent tissues (muscle, fat and
liver) can’t utilize glucose without insulin. Insulin as a conductor of glucose into tissues is
absent. That is why all the glucose rests in the blood and a result energetic deficiency is
developed. It stimulates secretion of contrinsulin hormones to activate glyconeogenesis and cope
with energetic deficiency. Glycemia blood level increases more and more and results in
hyperosmolality. It causes such symptoms as polyuria and polydipsia. Energetic deficiency and
metabolic changes lead to weight loss and polyphagia.
2. Paradiabetic Syndrome (Syndrome of small signs).
1. Skin and mucous membrane affection
Relapsed furunculosis, acne, eczema etc.;
Genital and skin itching;
Slow wound recovering.
2. Dental and oral cavity pathology
Paradontosis;
Relapsed stomatitis and gingivitis;
Active dental caries.
3. Eye pathology
Cataract.
4. Reproductive system disfunction
Erectile disfunction;
Menstrual disorders;
Loss of libido.
5. CNS disfunction
Memory impairment
Poor concentration and intellectual fatigability
2
