Postgrad Med J: first published as 10.1136/pgmj.23.258.185 on 1 April 1947. Downloaded from THE DIAGNOSIS AND TREATMENT OF GLYCOSURIA By STELLA INSTONE, M.D., M.R.C.P. Assistant Physician, New Sussex Hospital for Women, Brighton Part I. The Diagnosis of Glycosuria I. Diabetic Glycosuria When a young adult complains of thirst, Introduction excessive hunger, polyuria, exhaustion and Since glycosuria is often found only on loss of weight, the discovery of glycosuria routine examination of the urine, the impor- usually confirms an obvious diagnosis of tance of this simple procedure in every case is Diabetes Mellitus. Milder cases, especially in obvious. Unless this symptom is severe or patients over middle age, may have less marked long-standing, many of these patients make no symptoms. Minor degrees of wasting and suggestive complaint when first seen. lassitude should not be dismissed without When .a reducing substance is found in the examination of the urine, together with a glucose tolerance test, or at least a urine, it is necessary to prove that it is glucose. fasting by copyright. Fehling's solution should not be used, since blood-sugar estimation, if glycosuria is found. this reagent is reduced not only by sugar, but Sometimes one of the complications of also by uric acid, glycuronic acid and diabetes may first suggest the need to test the creatinine; the degree of reduction is slight, urine. Thus the patient may present with usually only a change in colour to green or recurrent boils, carbuncles or other septic vellowish-green. The more delicate Benedict's infection. It is important in such cases not to test may detect such sugars as lactose, laevulose miss a diabetic origin, so that the patient may be or pentose, which need more elaborate tests for properly prepared for any operative treat- http://pmj.bmj.com/ their identification. ment needed. Lactosuria is suggested by the presence of Pulmonary tuberculosis *is common in sugar in the urine during pregnancy or lacta- diabetics, and its symptoms may be few and tion, or when breast-feeding is suddenly undetected unless the chest be X-rayed in stopped. Lactose is identified by the yeast- every case. Less often, the pulmonary lesion fermentation test (glucose being the only sugar may cause symptoms before diabetes is which ferments yeast), and by the characteristic suspected; in these cases a urine test is most on September 29, 2021 by guest. Protected 'hedgehog' crystals of lactosazone. Laevulo- important. suria may occur during the course of liver Nervous symptoms may have a diabetic disease. Pentosuria is extremely rare. basis. In addition to peripheral neuritis, pains The usual type of glycosuria is due to the in the legs resembling sciatica may be associated presence ofglucose in the urine. Four varieties with diabetes, without other suggestive will be considered. symptoms. I. Diabetic Glycosuria. In severe diabetes the tendon reflexes may II. Renal Glycosuria. be absent, and paraesthesia and signs of posterior column involvement may lead to a III. Glycosuria of Cerebral Origin. suspicion of tabes unless their origin is IV. Glycosuria of Endocrine (non- appreciated. In cases of failing vision, the pancreatic) origin. urine should always be tested; diabetic Postgrad Med J: first published as 10.1136/pgmj.23.258.185 on 1 April 1947. Downloaded from i86 POST-GRADUATE MEDICAL JOURNAL APril, I 947 cataract and retinitis can be improved, or at Alimentary Glycosuria least 'arrested in their progress, by early In this condition, after a large meal of treatment. carbohydrate, the patient passes sugar in the urine. There may be no diabetic symptoms, Coma and renal glycosuria may be suspected, but a In every unconscious patient, whatever the glucose tolerance test will show that the blood history, the urine must be examined for sugar, sugar rises abnormally high and takes unduly acetone bodies and albumen. The finding of long to return to its fasting value, which may glycosuria and ketosis strongly suggests be above the normal. These cases are diabetic coma,' but some cerebral lesions may essentially mild diabetics, with lowered carbo- produce these signs (q.v.). If there is a history hydrate tolerance, in which the insulin of previous diabetes the diagnosis is simple. produced is enough to deal with average, but Useful confirmatory signs are' the low ocular not heavy, carbohydrate meals. The transient tension (rarely found except in conditjons of glycosuria sometimes found in fat, hypertensive dehydration leading to coma), dry skin, lips women after middle age, is probably of this and tongue, a smell of acetone in the breath nature. and, if available, laboratory findings showing hypeiglycaemia and a lowered alkali reserve. II. Renal Glycosuria If blood sugar estimations are not available, The normal renal threshold for sugar, is the distinction of hypoglycaemia from diabetic about i8o mgm. per cent. and above this leval coma may be difficult. In the former, the onset the storage mechanisms prevent a further rise is more sudden, the skin moist and sweating of blood sugar. In cases of renal glycosuria, and the ocular tension -normal. Sugar and the renal threshold is lower than normal, and acetone are usually absent from the urine, at these patients pass sugar in the urine when the by copyright. least, in the second specimen obtained. The blood sugar is only I40-I50 mgm. per cent., immediate response to the giving of sugar in' or less. The patient is usually a healthy young hypoglycaemia is also diagnostic. adult without diabetic symptoms. He may Glycosuria may be an incident in coma due complain of recurrent boils, or of local pruritus, to poisoning, uraemia or a cerebral vascular but the glycosuria is often found only on lesion; in such cases there will be charac- routine examination. A glucose tolerance test teristic physical signs. Even when glycosuria shows that' the fasting blood sugar is rather is found, every comatose patient should, be low and that the blood sugar never, rises above http://pmj.bmj.com/ thoroughly examined to make sure that no i8o mgm. per cent.-usually'not above I50 lesion other than diabetes is present. In mgm. per cent.-but that sugar appears in the particular, one should note the state of the urine each time its blood level exceeds I40-150 reflexes, cranial nerves and pupil reactions, mgm. per cent. This test is the only certain also, the presence of any needle marks or signs method of diagnosing renal glycosuria. of poisoning. The breath may smell of acetone and so lead to the detection of III. Glycosuria of Cerebral Origin on September 29, 2021 by guest. Protected glycosuria. Since Claude Bernard first described glyco- When the cause of coma is in doubt, lumbar suria following puncture of the floor of the puncture should be done to exclude the fourth ventricle, the condition has been noted presence of a subarachnoid haemorrhage. In in many basal cerebral lesions. When neuro- some cases of severe diabetic coma, the logical signs predominate the case, and presence of albumen and casts in the urine glycosuria is incidentally found, there is no may suggest uraemia and may cause neglect of difficulty in diagnosis. Some difficulty may the essential treatment with insulin and arise from lesions near the fourth ventricle in glucose. In every case of coma the urine which glycosuria precedes other signs. should be examined for albumen and sugar In some cases of cerebral haemorrhage, and, if possible, the blood urea should be glycosuria and even acetonuria may occur- estimated. the latter following starvation and vomiting. Apl I947 DIAGNOSIS AND TREATMENT OF GLYCOSURIA I87 Postgrad Med J: first published as 10.1136/pgmj.23.258.185 on 1 April 1947. Downloaded from Subarachnoid haemorrhage is suggested by adrenalin upon the blood sugar. Great the sudden onset of intense headache, coma emotional disturbances may possibly produce and signs of meningeal irritation, often with glycosuria by means of an outpouring of glycosuria. The cerebrospinal fluid, first adrenalin. Such an effect would be transient, bloodstained and later stained yellow, is under but it is possible that prolonged mental strain greatly increased pressure, and is diagnostic. might, by the same mechanism, cause diabetes. Internal capsular haemorrhage may track This would explain the common development into the ventricle; but in this coma the onset of diabetes in times of stress. Any disturbance is more rapid than in diabetic coma, and there of function of the ductless glands which are some localizing signs, e.g., hemiplegia and antagonize the pancreas may, if sustained, conjugate deviation of the eyes. cause true diabetes. Glycosuria occurring, for Tuberculous meningitis occurs especially in example, in hyperthyroidism, cannot therefore childhood, in which diabetes is uncommon. be dismissed as unimportant. Even through glycosuria may coexist, the presence of meningeal irritation, ocular pareses Summary of Differential Diagnosis of and raised intracranial pressure should Glycosuria establish the diagnosis. i. The importance of routine examination of the urine is stressed. IV. Endocrine Glycosuria 2. If sugar is found, it must first be identified Sometimes diabetes is part of a generalized as glucose. pancreatic insufficiency; these cases show 3. If glycosuria is accompanied by hunger, other signs such as chronic dyspepsia, steator- thirst, polyuria, loss of weight and lassitude, rhoea, raised blood and urinary diastase, and the diagnosis is diabetes mellitus. a positive Loewi's adrenalin test. The signs Recurrent 4. septic infections, cataract or by copyright. may be due to pancreatitis, neoplasm or retinitis, pulmonary tuberculosis or other syphilitic infection. well-known complications of diabetes, should Glycosuria is not uncommon in thyroid and always call for an examination of the urine. pituitary diseases; the thyroid, pituitary and 5. Inconstant glycosuria in a healthy young suprarenal hormones antagonize insulin, so adult is probably due to a low renal threshold that their hypersecretion may cause a state of for sugar.