Hyperosmolar Hyperglycemic Nonketotic Coma Research Articles

PSUN262 A Case of Hypoglycemia and Diabetic Ketoacidosis in an Adult with Down Syndrome

Abstract Introduction Down syndrome is associated with a higher risk of autoimmune endocrinopathies including diabetes mellitus. Due to intellectual disabilities characteristic of Down syndrome, good glycemic control of insulin-dependent diabetes can be challenging with several reports of complications in the literature. We present an adult female with several admissions for hypoglycemia and DKA. Case Presentation A 52-year-old female with a notable past medical history of insulin-dependent diabetes mellitus, hypothyroidism, and Down syndrome with intellectual disability equivalent to a 12-year-old presented to the emergency department unresponsive with a point of care blood glucose of 21 mg/dL. Dextrose 10% was given by EMS en route to the ER with improvement in the blood sugars to 118 on arrival. Her hemoglobin A1c was 7.1%. Of note the patient was taking insulin detemir 24 units in the morning and 30 units in the evening and metformin 1g BID. She was not checking her blood sugars before self-injecting and was skipping meals while injecting insulin. Caregiver fatigue was also reported. She was admitted one month ago for similar hypoglycemia. She was taken off insulin and continued her metformin. Her blood glucose was at inpatient goals by discharge. One month later, the patient presented with altered mentation and a point of care blood glucose greater than 600 mg/dL. Her glucose on chemistry panel was 732 mg/dL, anion gap was 21 mEq/L, bicarbonate was 21 mmol/L, and her beta-hydroxybutyrate was 1.67 mmol/L. Calculated serum osmolality was 316 mOsm/kg. The patient was admitted for DKA with a possible component of hyperosmolar hyperglycemic nonketotic coma. She was placed on a DKA protocol with an insulin drip and isotonic fluids then switched to subcutaneous insulin once her anion gap closed. She was then placed on 20 units insulin detemir daily and discharged. The patient then presented 2 weeks later with 2 days of no oral intake complicated by septic shock of unclear origin. After discussion with the mother, the patient was transitioned to comfort care and died 4 days later. Conclusion Our case illustrates the difficulty of glycemic control in patients with Down syndrome and diabetes complicated by caregiver fatigue, intellectual disability, and a complex insulin regimen. Clinicians should aim for a balance between glycemic control and treatment regimen simplicity while avoiding hypoglycemia and ketoacidosis. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Acute Occlusion of the Lower Limb Artery Associated with Hyperosmolar Hyperglycemic Nonketotic Coma in a Patient with Amyotrophic Lateral Sclerosis: A Case Report

A 61-year-old man with amyotrophic lateral sclerosis (ALS) on tracheostomy positive pressure ventilation was brought to the emergency room due to decreased consciousness. He was diagnosed with hyperosmolar hyperglycemic nonketotic coma (HHNC) with severe systemic hypotension. He exhibited an adequate response to treatment of continuous intravenous insulin infusion and fluid replacement. On the third day, he developed acute limb ischemia due to extensive occlusion from the left common iliac artery to the femoral artery.

MON-LB122 Psychiatric Medication Induced Diabetes Mellitus

Psychiatric medications are well established cause of diabetes. Our case had similar presentation. 67-year-old African-American male with history of hypertension and dementia was brought to the ER for auditory hallucination and bizarre behavior. His home medications were Hydrochlorothiazide, Nifedipine and Spironolactone. Psychiatry was consulted and he was admitted to psychiatric floor. He was diagnosed for first time with psychosis and depression. He was treated with citalopram 20 mg for depression; donepezil 10 mg for dementia and risperidone 0.5 mg twice a day for psychosis. 2 weeks later he developed difficulty swallowing and weakness, blood glucose level of 1263 mg/dl. All of his psychiatric medications were stopped except for citalopram 10 mg daily and patient was transferred to ICU. In the ICU, pH was 7.28 (normal 7.34-7.45), normal anion gap, bicarbonate 29mmol/L (normal 20-24), plasma osmolality 428 mOsm/kg (normal 280-320), HbA1c 10% (normal 4-5.6). He was intubated and managed as Hyperosmolar Hyperglycemic Non-Ketotic coma (HONK). He was started on insulin drip and later transitioned to Lantus and short-acting insulin. He improved and was then extubated. After 40 days, repeat A1C was 7.4%. The patient moved to another state and follow-up was lost.Discussion While the patient was on thiazide for a long time, he had a fairly good glucose control; his A1C ranged from normal to prediabetic (A1c 5.7%-6.4%). This makes thiazide unlikely cause of diabetes mellitus for him. The fact that right after 21 days of starting psych medications caused him to land in ICU for HONK, with A1c of 10% and glucose of 1273 mg/dl, strongly suggests that this is a case of psych medications induced T2DM. This is also supported by the fact that discontinuation of those medications lowered the A1c to 7.4% in 40 days. 3 weeks before the hospitalization his A1c was 5.1%. Metformin is demonstrated to be most promising long term medication in cases like this.Conclusion Psychiatric medications are important cause of drug induced diabetes and should always be thought as a cause of acute new onset diabetes. Stopping the offending drugs ensues good glycemic control.

Pulmonary aspergillosis is a rare finding in diabetic patients: a case report

Background: Aspergillosis is an infection caused by a common mold (type of fungus) named Aspergillus. Its spores are present in air but usually do not cause any disease in immune-competent people. However, it can cause various types of diseases, which most commonly involve the respiratory system. Early recognition and treatment are important for better outcomes. Case Presentation: A middle-aged diabetic male presented with high blood glucose levels leading to hyperosmolar hyperglycemic non-ketotic coma and was treated accordingly. His baseline chest X-ray showed reticulo-nodular shadowing and cavitatory lesion in left middle zone and was being treated on the lines of pneumonia. After 4 days of treatment, the patient did not improve and had had contrast enhanced CT-scan chest showing a reverse halo sign along with a fungal ball in the lung cavity. His white blood cells were increased, erythrocyte sedimentation rate was normal, and sputum for acid-fast bacilli was negative, but positive for Aspergillus species. Conclusion: Diagnosis of pulmonary aspergillosis was made and the patient was managed accordingly with intravenous antifungal therapy. Early diagnosis and treatment is necessary.

Retrospective analysis of diabetic hyperosmolar hyperglycemia complicated with rhabdomyolysis

Objective To investigate the clinical characteristics and treatment strategies of diabetic hyperosmolar hyperglycemia (HHS) with rhabdomyolysis (RM). Methods The clinical data of 40 patients with HHS treated in the General Hospital of Shenyang Military Command from November 2013 to November 2017 were retrospectively analyzed.According to the serum levels of creatine phosphokinase and myoglobin, they were divided into RM group (12 cases) and non-RM group (28 cases). The clinical characteristics and treatment results of the two groups were compared. Results There were 12 cases in the RM group, 6 cases were diagnosed RM at the time of consultation, and 6 cases developed RM during the course of treatment.Compared with the non-RM group, RM group had lower systolic pressure[(98.3±17.8)mmHg vs.(128.0±18.1)mmHg, t=4.823, P=0.000], higher blood glucose level[(44.4±14.0)mmol/L vs.(32.6±8.1)mmol/L, t=2.717, P=0.016], and more acidosis, mainly manifested by lower pH[(7.16±0.15)vs.(7.32±0.13), t=3.355, P=0.002], lower bicarbonate[(12.92±5.23)mmol/L vs.(19.07±6.80)mmol/L, t=2.792, P=0.008], higher blood D-3 hydroxybutyric acid [(5.84±2.98)mmol/L vs.(2.55±2.13)mmol/L, t=4.012, P=0.000], and renal function was worse[creatinine (257.1±149.8)μmol/L vs.(148.1±85.3)μmol/L, t=2.925, P=0.006]. Individualized rehydration and low dose insulin were given to control blood sugar, and increasing blood pressure, kidney protection, correction of electrolyte disturbance, anti-infection and inhibition of gland secretion were given to the complications.Hydration and alkalization were given to 7 cases of RM, and continuous renal replacement therapy (CRRT) was given to 5 cases.In 10 cases of HHS with RM, creatine kinase decreased, renal function recovered, and 2 patients died. Conclusion It is very important to improve the understanding of RM in HHS patients, routinely monitor the dynamic changes of muscle enzymes, make a good early diagnosis and prevention of RM.Urine hydration and alkalization should be given in time after RM occurs, and CRRT treatment as early as possible can improve the survival rate of diabetic patients. Key words: Diabetes mellitus; Hyperglycemic hyperosmolar nonketotic coma; Diabetic ketoacidosis; Rhabdomyolysis; Creatine kinase; Myoglobin; Acute kidney injury; Rehydration solutions; Renal replacement therapy; Retrospective studies

Analysis of Hyperlipidemia Pattern in newly Diagnosed Diabetic Patients

Objective : To analyze hyperlipidemia patterns among newly diagnosed young diabetic patients. Study Design : A descriptive cross-sectional study. Place and Duration: Study was conducted in Nawaz Shareef Medical College and Rawalpindi Medical University from Jan 2017 and Jan 2018. Methodology: All the patients were young and newly diagnosed with Diabetes Mellitus. Data collection was done via non probability consecutive sampling included patients’ demographics, past medical history, co-morbidities, and lab findings were assessed. SPSS version 24 was used to analyze data. P value ≤ 0.05 was taken as significant. Results : Eighty patients were included in this study. Diabetic nephropathy, diabetic retinopathy, macrovascular complications, hyperglycemic hyperosmolar non-ketotic coma history, family history and hypertension were noted in n=12 (15%), n=6 (7.5%), n=9 (11.3%), n=1 (1.3%), n=34 (42.5%) and n=11 (13.8%) respectively. The mean hyperlipidemia, hypertriglyceridemia, of the patients was 4.54±0.52 mmol/L, 2.59±1.13 mmol/L, 1.39±0.80 mmol/L, 1.03±0.59 mmol/L respectively. Conclusion : the study has shown that the prevalence of increased levels of triglycerides is more than increased LDL cholesterol levels among these patients. As it has been established that hypertriglyceridemia is a known risk factor for causing cardiovascular disorders among diabetic patients, it should be addressed and managed accordingly at the onset of diabetes. Key words : Hyperlipidemia, Diabetes Mellitus, low density lipoproteins, high density lipoproteins, insulin. DOI : 10.7176/JMPB/62-08 Publication date: December 31 st 2019

Hyperglycaemic Hyperosmolar State (HHS) in children: a practical guide to management

Abstract Hyperglycaemic Hyperosmolar State (HHS), also known previously as Hyperosmolar Hyperglycaemic Non-Ketotic Coma (HONK) is a life-threatening but preventable acute metabolic complication of diabetes. It is becoming more common in childhood and optimal outcomes require a good understanding of the condition. It is very important that HHS is distinguished from DKA, as the management differs significantly, and HHS has a high morbidity and it can prove fatal. This review discusses the pathophysiology, how to make the diagnosis and the recommended treatment of this condition in children. The best clinical management of HHS in childhood involves careful correction of fluids and biochemical status of the patient and identification of precipitating causes whilst carefully monitoring for complications.

Hyperosmolar hyperglycemic nonketotic coma after chemoradiotherapy for esophageal cancer

A 73-year-old man was diagnosed with a type 2 tumor in the middle third of his esophagus by upper esophagogastrointestinal examination and an esophagogram; the tumor was diagnosed as squamous cell carcinoma by endoscopic biopsy. Computed tomography (CT) revealed that the tumor had invaded his descending aorta. He was diagnosed with T4b/N0/M0 stage IIIc [Union for International Cancer Control (UICC), 7th edition] esophageal cancer. He had no previous history of diabetes mellitus. We treated him with concurrent chemoradiotherapy using cisplatin and 5-fluorouracil. Fourteen days after the entire course of chemoradiotherapy, he became confused and entered into sudden coma, which was diagnosed as hyperosmolar hyperglycemic nonketotic coma. With vigorous intravenous infusion of half-saline and insulin, he recovered from the coma 36 h after onset. Hyperosmolar hyperglycemic nonketotic coma is a severe complication that is difficult to treat and can be induced by chemoradiotherapy. It must be diagnosed early and treated appropriately.

Tips for GP trainees working in acute medicine

The medical admissions unit (MAU) is a perfect opportunity to hone your skills in history taking, examination, investigations, and management of both the common medical presentations and also rarer conditions. It also provides an environment where you can develop communication and management skills while running the take, delegating to your on-call team, and prioritising unwell patients. You will experience referrals from the community as well as from the accident and emergency (A&E) department. These interactions will be very helpful in improving your telephone consulting skills and referral technique. As the acute medical team you have a rare opportunity to see a breadth of presentations and conditions, to develop brilliant communication skills, and use them to help your patients and their relatives understand what we're doing to them and why! This article aims to provide a guide to help you through a typical job on the MAU, that will allow you to feel more prepared for the days ahead and the expectations on you as the senior house officer (SHO). 1. Your F1/medical student days are over, when clerking you have to ‘hang your hat’ and diagnose! Try to come up with differentials and write them down, it will make you think! Assess the patient clinically, don't just hang on for chest X-rays (CXR) and bloods. 2. Familiarise yourself with the common presentations to the MAU and the immediate management of these patients, in particular chest pain, shortness of breath, sepsis, cough, weakness, ‘off legs’, diabetic ketoacidosis, hyperosmolar hyperglycaemic non-ketotic coma, and renal failure to name but a few. 3. …

Fulminant Emphysematous Pyelonephritis (EPN) in a Diabetic Patient Suspected of Having Multiple Tumors

Multiple tumors in the liver, kidney, and on the posterior side of the urinary bladder were accidentally found when a diabetic woman visited the hospital. She refused to undergo surgery; therefore, she was only observed for 2 months. Subsequently, she was found unconscious at home and diagnosed with urinary infection, sepsis, and hyperglycemic hyperosmolar non-ketotic coma. The case followed a fulminant course, and she soon died. Postmortem computed tomography revealed emphysematous pyelonephritis (EPN), a rare, life-threatening infection. This case highlights the importance of carefully managing infection in diabetic patients, and it may contribute to clarifying the pathogenesis of EPN.

Severe Hyperglycemic Hyperosmolar Nonketotic Coma in a Nondiabetic Patient Receiving Aripiprazole

Aripiprazole is commonly used as an atypical antipsychotic. It has been associated with abnormalities in glucose metabolism. Severe diabetic complications associated with its use occur rarely. We present a case of a patient without a history of diabetes mellitus who presented to the emergency department in severe hyperosmolar nonketotic coma while using aripiprazole.

Hyperglucagonemia - a Potent Threat which can Worsen the Diabetes Mellitus

Background: Diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic coma (HHNK) are two serious acute complications of diabetes mellitus. DKA consists of the biochemical triad of hyperglycemia, ketonemia and acidemia. In DKA and HHNK dehydration and sodium depletion is seen. Lack of insulin causes hyperglycemia and also inhibits entry of potassium into the cells leading to hyperkalemia. Moreover Hyperglucagonemia also contributes to hyperglycemia and can worsen the diabetic state. Study Design: This study was retrospective, analytical case control study. Non - probability convenient sampling technique was used. Materials and Methods: We reviewed the hospital admissions and patients coming to OPD with type1 & 2 diabetes mellitus as well as diabetic complications like diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic non-ketotic coma (HHNK). We compared the groups for plasma glucose, plasma osmolality, plasma glucagon, serum electrolytes and arterial blood gases (ABGs) with control group. Results: Twelve persons were considered as control being non-diabetic with normal oral glucose tolerance. Mean plasma glucose level & mean plasma osmolality level in the patients of uncontrolled type 2 diabetes mellitus, uncontrolled type I diabetes mellitus, DKA and HHNK was significantly higher (p < 0.001) as compared with control subjects. Mean plasma glucagon level in the patients of uncontrolled type I diabetes mellitus and DKA was found significantly higher (p < 0.001) as compared with control subjects. Serum potassium level was significantly higher in patients of uncontrolled type 2 diabetes mellitus, uncontrolled type 1 diabetes mellitus, HHNK (p <0.001) and DKA (p <0.01) as compared with control subjects. Arterial pH was significantly lower in patients of DKA (p < 0.001), uncontrolled type 1 diabetes mellitus (p < 0.05) and HHNK (p < 0.01). Arterial PCO 2 was significantly lower in patients of DKA (p < 0.05). Plasma bicarbonate levels were found significantly lower in patients of DKA (p < 0.001) and HHNK (p < 0.01). Discussion: The present study showed that in type 1 DM hyperglucagonemia was more marked leading to excessive ketone bodies production and resulting in DKA. The ketoacids formed during DKA are strong acids that fully dissociate at physiological pH. So ketonuria lead to excretion of positively charged cations (Na + , K + , NH 4 + ). Moreover, the hydrogen ions were titrated by plasma bicarbonate ions, resulting in metabolic acidosis and retention of anions lead to increase in the plasma anion gap in DKA. The degree of hyperosmolality and hyperglycemia was more marked in patients with HHNK as compared with DKA. The osmotic effects of glycosuria resulted in impairment reabsorption of NaC1 and H 2 O and ultimately hyponatremia. Whereas Serum potassium level was found to be significantly higher in uncontrolled type I diabetes mellitus, uncontrolled type 2 diabetes mellitus, DKA and HHNK. These observations were according to the results of previous studies. Conclusions: Hyperglucagonemia causes marked hyperglycemia under conditions of relative insulin deficiency and can worsen the diabetic state like development of DKA when insulin deficiency becomes absolute as in type 1 diabetes mellitus. Key words: Diabetes mellitus (DM), diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic non-ketotic coma (HHNK), arterial blood gases (ABGs), plasma osmolality.

インスリン導入が遅れ高血糖高浸透圧昏睡を来たした高齢者糖尿病の1例

A 79-year old woman was admitted with disturbed consciousness (JCS II-30). She had been given a diagnosis of type 2 diabetes 7 years previously, and was being treated with oral hypoglycemic agents. She also suffered Alzheimer's disease and Parkinson's disease. Plasma glucose and HbA1c upon admission was 676mg/dl and 9.7%, respectively. Serum Na was 153mEq/l. Urine ketone body test was negative and metabolic acidosis was not observed. Hyperglycemic hyperosmolar non-ketotic coma (HHNC) was diagnosed, and treatment was started immediately with normal saline infusion. Continuous infusion of regular insulin was needed to lower blood glucose. Disturbed consciousness and dehydration improved by the third hospital day. However, she became bedridden afterwards and received tube feeding. Up to 46 units of insulin was needed daily to control blood glucose. Urine C-peptide secretion was very low (10microg/day), suggesting that insulin therapy was essential for glycemic control long before admission. It is thought that a number of elderly diabetic patients who need insulin therapy do not receive or continue it for various reasons. Discussion is necessary to grasp the actual situation and defensive actions that can be taken.

Clinical Pictures of 5 Cases of Hyperglycemic Hyperosmolar Non-ketotic Coma in the Elderly

Clinical Pictures of 5 Cases of Hyperglycemic Hyperosmolar Non-ketotic Coma in the Elderly

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Pathophysiology of Diabetes Mellitus

As we learn more about the pathophysiology of diabetes mellitus, we find that there is more yet to be learned. This may sound like a trite statement, but in reality it is true. The following article reviews the basic pathophysiology of both type 1 diabetes mellitus and type 2 diabetes mellitus as we understand it today. It continues on to reveal the "things that go wrong" when there is too much or too little glucose available to the body organs and especially to the brain. The article points out the signs and symptoms to be aware of when the person is in the acute state of diabetic ketoacidosis, hyperglycemic hyperosmolar nonketotic coma (or state), and severe hypoglycemia. It concludes with important considerations when the individual is in one of these acute states and contributes key points related to the control of diabetes when the person is in the state of compromise.

Hyperosmolar hyperglycaemic nonketotic coma associated with acute myocardial infarction: report of three cases

Diabetes mellitus is one of the most commonly associated diseases of patients suffering an acute myocardial infarction. Although the coexistence of acute myocardial infarction with other clinical manifestations of diabetes have been well described, extremely few data exists about the concomitant occurrence of hyperosmolar hyperglycaemic nonketotic coma and myocardial infarctions. This article presents three patients with this association and aimed to discuss the clinical course and treatment strategies of this rare condition.

Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) Accompanied with Acute Renal Failure, Rhabdomyolysis and Acute Obstructive Hydrocephalus.

A 65 year-old female was admitted to a regional hospital with a complaint of ileus following a total hysterectomy performed 14 years ago. She was treated conservatively by total parental nutrition (TPN). Nine days later she underwent resection of the intestine due to rebound tenderness in the lower abdomen. Infusion toward TPN was resumed the following day after the operation. On the 4th postoperative day she developed restlessness and stupor. She was treated as a hyperosmolar hyperglycemic nonketotic coma (HHNC). She was referred to our intensive care unit (ICU) due to coma and hypotension. Her conscious level was a score of 5 on the Glasgow Coma Scale (GCS). Continuous hemodiafiltration (CHDF) was introduced intermittently due to oliguria. During these treatments, she fell into a deep coma and almost stopped spontaneous respiration on the 10th hospital day. CT scans showed a marked brain stem edema and acute obstructive hydrocephalus. She underwent an emergency ventricular drainage. After these treatments, her consciousness level gradually recovered and subsequently she was transferred to the general ward with a score of 13 on the GCS. Although she had serious complication of renal failure, rabdomyolysis and also hydrocephalus in this case, she was recovered in intensive care. It is advisable to maintain the patients on clinical parameters (monitoring therapy) using CHDF.

The prognostic factors of adult Gram-negative bacillary meningitis

Seventy-seven patients with Gram-negative bacillary meningitis (GNBM), 57 males and 20 females, aged 17–86 years, were identified at Kaohsiung Chang Gung Memorial Hospital, over an 11-year period. Fifty-four infections were community-acquired, and 23 were nosocomial; 49 were spontaneous and 28 occurred after head surgery or neurosurgery. The organisms most frequently involved were Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, and Acinetobacter. Rarer pathogens included Citrobacter species, Serratia marcescens, Enterobacter cloacae, and Proteus mirabilis. All patients who did not receive appropriate antibiotic therapy died. The mortality in those treated with appropriate antibiotics was 28%. Other statistically significant prognostic factors included septic shock, initial level of consciousness, hyperosmolar hyperglycemic nonketotic coma, disseminated intravascular coagulation, high cerebrospinal fluid lactate levels and leucocytosis. In the multiple logistic regression analysis, only appropriate antimicrobial therapy and septic shock were strongly associated with mortality even after adjusting for other potentially confounding factors. Despite the high mortality, management can be improved by early diagnosis, early use of appropriate antibiotics, and correction of underlying and associated medical derangement.

Comas hyperosmolaires du diabétique. Facteurs pronostiques. À propos de 55 observations

Fifty five consecutive patients (mean age 70 ± 12 yr) with hyperosmolar hyperglycemic nonketotic coma were studied retrospectively to identify prognostic factors. Age, admission levels of blood glucose, plasma osmolality, serum sodium were no related to death. Prognostic factors were shock, coma, acute respiratory falture and simplified acute physiology score.