ESPE Abstracts

Introduction: Hyperglycemic hyperosmolar state (HHS) and diabetic ketoacidosis (DKA) are life-threatening emergencies in diabetic patients. While DKA at presentation of T1D in children represents about 25% of cases, HHS is very unusual as a first presentation.

Case: A 10 year old Haitian-Sudanese boy presented to our ER for obtundation. He had a 10 day history of polydipsia and polyuria followed later by vomiting, for which he drank mainly juice and soft drinks. On the day of presentation, he had difficulty rousing. In ER, he was tachycardic and hypotensive with a GCS of 8. Initial labs showed pH 7.1, bicarb 9.2, glucose 130mmol/l, Na 125mmol/l, K 4.0mmol/l, creatinine 352umol/l, urea 25.2mmol/l, and mild ketonuria. He was started on our DKA protocol after receiving three fluid blouses for hypovolemic shock. Urgent CT and MRI head were normal. The patient was admitted to ICU for management of profound dehydration, requiring intubation and inotropes. HbA1c was found to be 11%. Repeat MRI brain on day 3 due to agitation revealed a superior sagittal and straight sinus thrombosis. Other complications during his hospitalization included unilateral vocal cord paralysis without a clear etiology and non-pressure ulcers over the ischia region and in the left gluteal fold. The patient was admitted for 34 days, the latter weeks dedicated mainly to wound care. He was discharged with only a residual vocal cord paralysis but a grossly normal neurological exam. His BG were well controlled on 1.2unit/kg/day of insulin.

Discussion: The classic presentation of HHS in children is usually in obese adolescents with T2D. The symptoms tend to occur more gradually, and the mortality rate from HHS is higher than that from DKA. Their fluid deficit is estimated to be double that associated with DKA alone, and as such tends to be grossly underestimated, especially by treating physicians who rarely encounter this condition. Our patient presented with both HHS and mild DKA and fortunately survived with few sequelae. At follow-up he had progressed to have remission (honeymoon period) lasting five months and continues to have well-controlled diabetes with the most recent HbA1c of 7.1% on 0.75unit/kg/day of insulin.