Special Course: Team-Based Learning

Noriyuki Koibuchi
Professor of Integrative Physiology
Gunma University, Japan

Today’s clinical case 1: Type I Diabetes Mellitus

A 15-year-boy was recently diagnosed with type I (insulin-dependent) diabetes mellitus. He was an
excellent student and had many friends. Before diagnosis, he had worried about several symptoms
that he experienced for 4 months. One day, at a sleepover in his friend’s house, the unimaginable
happened: He wet his bed! Until this tragedy, he had not told his parents about symptoms he was
having. He was constantly thirsty and was urinating every 30 to 40 minutes. Furthermore, despite a
voracious appetite, he seemed to be losing weight. His parents panicked because they knew that
these were classic symptoms of diabetes mellitus. They took David to see his pediatrician
immediately.

Physical examination and Laboratory Results

Height 169.5 cm
Weight 45 kg (decreased 4 kg in 2 months)
Blood pressure 90/55 (lying down), 75/45 (standing up)
Fasting plasma glucose 320 mg/dL (normal, 70-110 mg/dL)
Fasting C-peptide 0.05 ng/mL (normal, 0.4-2.2)
Plasma ketones l+ (normal, none)
Urinary glucose 4+ (normal, none)
Urinary ketones 2+ (normal, none)

All of the findings were consistent with a diagnosis of type I (insulin-dependent) diabetes mellitus.
He immediately started taking injectable insulin and learned how to monitor his blood glucose level
with a fingerstick.

Group discussion: Discuss following questions.

1.How did insulin deficiency lead to an increase in his blood glucose concentration?
Insulin lowers blood glucose levels and promotes carbohydrate storage by:
• Insulin facilitates glucose transport into most cells.
• Insulin stimulates glycogenesis, the formation of glycogen from glucose, in skeletal muscle and
liver. • Insulin inhibits glycogenolysis (the breakdown of glycogen into glucose).
• Insulin inhibits gluconeogenesis (the conversion of amino acids to glucose in the liver). Insulin
does this by reducing the amount of amino acids in the blood that are available to the liver for
gluconeogenesis and by inhibiting the liver enzymes needed to convert amino acids into glucose.
So deficiency insulin increase blood glucose concentration.

2. How did insulin deficiency lead to the finding of ketones in his blood and urine?
David's blood and urine contain ketones because a lack of insulin increases the levels of fatty acids
in the blood, which are the biosynthetic precursors of keto acid. Lack of insulin promotes the
catabolism of all nutrients, including fat. Increased lipolysis increases levels of fatty acids in the
blood which are converted in the liver into keto acid fl-hydroxybutyric acid and acetoacetic acid.
When the keto acid concentration increases in the blood, they are filtered, the glomerular
capillaries and appear in the urine.

3. Why did he have glucose in his urine (glucosuria)?

There is too much sugar in the body fluids because the lack of the insulin hormone, so renal
tubule fail to reabsorb all of the excess glucose, so some sugar passes into the urine.
4. Why did he have increased urine production (polyuria)? Why was he drinking so much
(polydipsia)?
Why did he have increased urine production?
When blood glucose levels are too high, our body will try to remove some of the excess glucose
via urination. This also leads to our kidneys filtering out more water, which leads to an increased
need to urinate.
Why was he drinking so much (polydipsia)?
polydipsia is caused by increased blood glucose levels. When blood glucose levels get high, our
kidneys produce more urine in an effort to remove the extra glucose from our body.
Meanwhile, because your body is losing fluids, your brain tells you to drink more in order to
replace them. This leads to the feeling of intense thirst associated with diabetes.

5. Why was his blood pressure lower than normal? Why did it decrease further when he stood
up?
Deficiency of insulin excretion, resulting in hyperglycemia. Hyperglycemia causes glucose in the
urine (glucosuria). Due to high glucose (hypertonic) in the kidneys, osmosis occurs to maintain
equilibrium. To overcome the increased concentration in the kidney tubules, water will be added
from the blood vessels to the kidneys, so that there will be a decrease of water in the blood and
the blood volume will decreased too. Decreased blood volume can lower the blood pressure.
When standing up, gravity moves blood from the upper body to the lower limbs. As a result,
there is a temporary reduction in the amount of blood in the upper body for the heart to pump
 (cardiac output), which decreases blood pressure

6. He takes his insulin by subcutaneous injection. Why can't he take insulin orally?
Insulin can't be taken orally to lower blood sugar because stomach enzymes will break down the
insulin, preventing its action. You'll need to receive it either through injections or an insulin
pump.