A 5-year-old girl is brought to the office due to "wetting the bed." Since age 3, she had been urinating and stooling while on the toilet during the day and night, with no accidents. However, for the past 2 weeks, the patient has wet the bed nightly. She is also more thirsty than usual, urinates more often during the day, and has had accidents at school. Review of systems is positive for fatigue and negative for dysuria and hesitancy. The patient has had no major illnesses and has met all developmental milestones. A month ago, the family moved to a new house after her brother was born. Vital signs are normal. Weight and height are at the 20th and 40th percentile, respectively, but both were at the 40th percentile at her well-child visit 3 months ago. Physical examination shows a tired-appearing girl. Mucous membranes are dry. The rest of the examination is unremarkable. Which of the following is the most likely explanation for this patient's symptoms?

Question

A 5-year-old girl is brought to the office due to "wetting the bed."  Since age 3, she had been urinating and stooling while on the toilet during the day and night, with no accidents.  However, for the past 2 weeks, the patient has wet the bed nightly.  She is also more thirsty than usual, urinates more often during the day, and has had accidents at school.  Review of systems is positive for fatigue and negative for dysuria and hesitancy.  The patient has had no major illnesses and has met all developmental milestones.  A month ago, the family moved to a new house after her brother was born.  Vital signs are normal.  Weight and height are at the 20th and 40th percentile, respectively, but both were at the 40th percentile at her well-child visit 3 months ago.  Physical examination shows a tired-appearing girl.  Mucous membranes are dry.  The rest of the examination is unremarkable.  Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d729_0812_bc81_bb6424f708aa_MD0003_00 Enuresis is urinary incontinence in children age ≥5. Children who have never achieved dryness have primary enuresis. Secondary enuresis refers to incontinence after ≥6 months of dryness. As shown in this case, secondary enuresis is often pathologic and requires evaluation. In addition to day and night incontinence, this patient has polyuria, polydipsia, and poor weight gain, findings suggestive of type 1 diabetes mellitus (DM). Type 1 DM, which results in insulin deficiency from autoimmune destruction of pancreatic beta cells, has a bimodal onset: Patients typically start having symptoms at age 4-6 or at early puberty. When hyperglycemia exceeds the renal threshold for glucose, the resultant glucosuria leads to osmotic diuresis and dehydration (eg, dry mucous membranes). Weight loss and fatigue are additional common presenting symptoms. Diagnosis is confirmed by elevated serum glucose or the presence of glucose in the urine. When euglycemia is achieved with insulin therapy, glucosuria and, in turn, polyuria and enuresis, resolve. (Choice B) Urinary tract infections can cause enuresis. However, most patients also have dysuria, hesitancy, and urgency, making this diagnosis less likely. (Choices C and D) Psychologic stress (eg, new home, birth of a sibling, parental divorce) can cause behavioral regression, including secondary enuresis. In addition, functional constipation causing stool retention in the distal bowel can lead to decreased bladder capacity and enuresis. Both causes should be investigated in a child with enuresis. However, fatigue, polydypsia, signs of dehydration, and weight loss would not be expected, so type 1 DM is more likely in this case. (Choice E) Nephrogenic diabetes insipidus, an impaired renal response to antidiuretic hormone, presents with polydipsia and excessive excretion of dilute urine. In contrast to type 1 DM, diabetes insipidus is rare in children and far less likely to cause this patient's symptoms. Educational objective: Enuresis in the setting of polyuria, polydipsia, and weight loss is suggestive of new-onset type 1 diabetes mellitus. References: Diabetes update: primary care of patients with type 1 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/28530380) Enuresis in children: a case based approach. (http://www.ncbi.nlm.nih.gov/pubmed/25369644)

A 5-Year-Old Girl Is Brought to the Office Due to "Wetting