Clinical Presentation Why's Diabetes May Be Missed?

Thirst, tiredness, pruritus vulvae or balanitis, polyuria, and
weight loss are the familiar symptoms of diabetes.

Why then isthe diagnosis so often missed?
Of 15 new patients with diabetes
presenting in our diabetic ward for the first time with
ketoacidosis, 14 had had no tests for diabetes after a total of
41 visits to their doctors.

Almost all these serious cases ofketoacidosis could have been prevented.
Patients do not, of course, always describe their symptoms
in the clearest possible terms, or else their complaints may
occur only as an indirect consequence of the more common
features.

Many patients describe dry mouth rather than thirst,
and patients have been investigated for dysphagia when
dehydration was the cause. Polyuria is often treated blindly with
antibiotics; it may cause enuresis in young people and
incontinence in elderly people and the true diagnosis is often
overlooked. Complex urological investigations and even
circumcision are sometimes performed before diabetes is
considered.

Confusion in diagnosis
Some diabetic patients present chiefly with weight loss, but
even then the diagnosis is sometimes missed, and I have seen
two teenagers referred for psychiatric management of anorexia
nervosa before admission with ketoacidosis. Perhaps weakness,
tiredness, and lethargy, which may be the dominant symptoms,
are the most commonly misinterpreted; “tonics” and iron are
sometimes given as the symptoms worsen.

Deteriorating vision is not uncommon as a presentation,
due either to change of refraction causing myopia (mainly in
Type 1 diabetes) or to the early development of retinopathy
(mainly in Type 2 diabetes).

Foot ulceration or sepsis in older
patients brings them to accident and emergency departments
and is nearly always due to diabetes. Occasionally painful
neuropathy is the presenting symptom, causing extreme pain in
the feet, thighs, or trunk.

Glycosuria itself is responsible for the monilial overgrowth
which causes pruritus vulvae or balanitis; some older men are
first aware of diabetes when they notice white spots on their
trousers. In hot climates drops of sugary urine attract an
interested population of ants, and at least one patient now
attending the clinic at King’s College Hospital presented in this
way before he came to England.