“Graves disease” behind glucose fluctuation

At 16:30 p.m., in the consulting room of Department of Endocrinology, there was only one patient left. As the queue system rang, a middle-aged woman came in. She was a common patient, and had been diagnosed with type 2 diabetes mellitus (T2DM) for five years. She often took oral biguanides and sulfonylurea to control blood glucose, and her blood glucose level was relatively stable. When she came in, I noticed that she was worried and upset, and I thought maybe that was ascribed to the long waiting.

“Hello, please take a seat. How is your blood glucose?” I asked. She was in low spirits, and answered, “well, my blood glucose was not stable recently. Please check for me”. She took out a blood glucose monitoring sheet, and after I checked it, I could understood her feelings. Her fasting blood glucose was around 10 mmol/L several times, with the postprandial blood glucose higher than 15 mmol/L, and blood glucose significantly higher the upper limit of normal.

Then, I started to look for the potential reasons for blood glucose fluctuation on the basis of diet, exercise and medication. Since the patient had a long history of T2DM, she followed the basic treatments. After she provided more information, I excluded the traditional factors causing blood glucose fluctuation. As it is known that poor sleep may also lead to blood glucose fluctuation in diabetes mellitus patients, I asked about her sleep, and learnt that she had terrible sleeping last month. She couldn’t fall in sleep again once be woken up at night.”

“How was everything going recently? Anything happened?”, I asked. She answered helplessly, “My son did not performed well in study at school recently, and is thus in bad tempered and became very thin. I’m so worried about him”.

After brief conversation, I suspected that her son might have “hyperthyroidism”. Therefore, I advised this patient to bring his son for examinations. Before she left the clinic, she looked much better.

The next morning, the patient and her son went into the clinic as planned. Her son was 14 years old, and complained of significant weight loss, accompanied with symptoms like palpitation, sweating, tremor and defecation 4 times daily. As is showed via physical examination, height 168 cm, weight 50 kg, bilateral thyroids II° enlargement, palpable tremor, vascular murmur, heart rate 108 beats per minute (bpm) with regular heartbeat, but no pathological murmurs were heard. After examination of thyroid function, thyroid ultrasonography, and thyroid iodine uptake measurement + imaging, her son was diagnosed with Graves disease. Then, I prescribed for the treatment of Graves disease.

After hospital visit, her son complied with standard treatment and I followed them up closely. Most of symptoms such as palpitations, sweating and tremor were significantly alleviated, and his academic performance was also improved steadily. The sleep quality of this patient was significantly improved and her blood glucose level gradually and stably controlled at an allowable range.

In clinical practice, some factors that cause the abnormal clinical manifestations may not be perceived. In respect of this case, we can also learn that clinicians should have a full communication with their patients, because one more sentence may even change the prognosis of two patients. For a medical practitioner, it is quite encouraging and comforting once the “hidden” factors are identified.

Acknowledgements

None.

Footnote

Conflicts of Interest: The author has no conflict of interest to declare.