Severe Hypernatremia in Combined Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Case Report of Two Japanese Children.

Saho Shima,Kikumi Ushijima,Shuichi Yatsuga,Miyuki Kitamura,Satoko Umino

doi:10.7759/cureus.9672

Abstract

As sodium level in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) is usually low, normal, or slightly elevated, severe hypernatremia with DKA and/or HHS is rare. Case 1 was a 14-year-old boy, presenting with typical laboratory test values and symptoms consistent with DKA and HHS. His corrected sodium level, 172 mEq/L, might have occurred as a result of consuming 6 L/day of highly carbonated, carbohydrate- and sodium-rich drinks during the week preceding the diagnosis. This patient developed right lung artery thrombosis, which did not require treatment. Case 2 was a 10-year-old girl, presenting with typical laboratory test values and symptoms of DKA and HHS. Her corrected sodium level, 175 mEq/L, might have occurred as a result of large electrolyte-free water loss associated with osmotic diuresis. These two cases of patients presenting with DKA-HHS and severe hypernatremia are the first to be reported in Japan.

Highlights

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are complications that present in the acute phase of diabetes mellitus (DM)
Combined diabetic ketoacidosis (DKA)-HHS syndrome is defined by the following laboratory values: 1) plasma osmolarity ≥ 320 mOsm/kg, 2) BG ≥ 600 mg/dL, 3) pH ≤ 7.30, and 4) ketonuria and/or ketonemia [5]
To the best of our knowledge, this is the first report of two pediatric cases of DKA-HHS with severe hypernatremia, including a case with complications of asymptomatic rhabdomyolysis, thrombosis of right pulmonary artery, pneumomediastinum, and subcutaneous emphysema simultaneously, in Japan

Summary

Introduction

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are complications that present in the acute phase of diabetes mellitus (DM). The patient has a height of 172.8 cm (+0.9 SD), body weight of 80.7 kg (+2.2 SD), and BMI of 27 kg/m2 (+1.7 SD) His treatment consists of 24 units/day of insulin degludec and 35 units/day of. He was diagnosed with T1DM, complicated with DKA-HHS and severe hypernatremia due to soft drink ketosis. Case 2 was a 10-year-old Japanese girl, with no significant past medical history She was born at 39 weeks of gestational age, with a birth weight of 3202 g (+1.1 SD) and birth length of 49.5 cm (+0.4 SD). Her treatment consists of 10 units/day of insulin degludec and 19 units/day of insulin lispro (0.87 units/body weight/day) She was diagnosed with T1DM, complicated with DKA-HHS and severe hypernatremia

Discussion

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Disclosures