A 15-year-old African American male was brought to the emergency department by ambulance in an obtunded state. The patient presented with a two-day history of vomiting, diarrhea, abdominal pain, general malaise and emotional distress. Before presentation, the patient experienced a recent history of polyuria and polydipsia of unknown duration. The patient did not have a primary care physician and this was his initial presentation to medical care. On arrival in the emergency room, the patient had a Glasgow Coma Scale score of 9. On examination, the patient was obese, with a body mass index (BMI) of 33 kg/m2. His blood pressure was 112/57 mmHg, with a heart rate of 146 beats/min (normal 60 beats/min to 100 beats/min), a respiratory rate of 60 breaths/min (normal 12 breaths/min to 16 breaths/min) with Kussmaul respirations and a temperature of 38.4°C. The patient’s pupillary response was sluggish and the patient was noted to have dry mucous membranes. Skin examination of the patient revealed acanthosis nigricans along the nape of his neck. The patient’s abdomen was slightly distended but soft.
Initial laboratory investigations confirmed a diagnosis of diabetes (). Of note, the patient’s blood glucose level was markedly elevated at 90.9 mmol/L (normal 3.4 mmol/L to 6.3 mmol/L), serum osmolality 454 mOsm/kg (normal 275 mOsm/kg to 295 mOsm/kg), pH 6.97 (normal 7.35 to 7.41), PCO2 23 mmHg (normal 38 mmHg to 50 mmHg), HCO3−5 mEq/L (normal 20 mEq/L to 25 mEq/L), Na+ 141 mEq/L (normal 135 mEq/L to 145 mEq/L with ‘corrected’ Na+ for hyperglycemia 165 mEq/L), K+ 8.4 mEq/L (normal 3.5 mEq/L to 5.0 mEq/L), and 1+ urine ketones. Hemoglobin A1C was elevated at 13.4% (normal 4.0% to 6.0%), indicating longstanding hyperglycemia.
Laboratory values at presentation
Other than some learning difficulties in school, the patient’s medical history was noncontributory. The patient had a sedentary lifestyle and had been obese for several years. There was a strong family history of T2D in maternal relatives.
The patient was admitted to the paediatric intensive care unit for further investigation and treatment. He was given a 6 mL/kg bolus for the first hour of intravenous (IV) treatment initially, which was reduced to 250 mL/h of 0.9% saline as per the institution’s DKA protocol. The initial fluid bolus was below current recommendations for HHS because the patient’s weight was initially underestimated by approximately 30 kg. Furthermore, due to his normal blood pressure and obesity, his level of dehydration was also initially underestimated. The patient’s lack of hypotension at presentation was likely due to pre-existing hypertension, which was unmasked and sustained after appropriate rehydration. The patient developed cardiac arrhythmia secondary to hyperkalemia 3 h after IV fluids were initiated. Insulin infusion was started to treat hyperkalemia at 0.03 units/kg/h with dextrose added to the IV fluids. Within the first 12 h of treatment, he developed status epilipticus and required intubation and ventilation. Additional acute complications within the first two days of treatment included severe hypernatremia (peak level 181 mEq/L), acute renal failure, rhabdomyolysis, hypertension and pancreatitis. Computed tomography and magnetic resonance imaging of the patient’s brain were normal, with no indication of cerebral edema or thrombosis. IV fluids and insulin infusion were titrated to slowly bring serum glucose and sodium levels into the normal range.
The patient’s seizures resolved on the second day of admission, he was then extubated on the fourth day of admission and transferred out of the intensive care unit. The patient was significantly deconditioned and required 35 days of rehabilitation before discharge from hospital. Initially, he was not able to ambulate without assistance, but was able to do so independently at discharge. His current medications include subcutaneous insulin, metformin and fosinopril. In follow-up, the patient has returned to his previous level of cognitive functioning. To date, he has been nonadherent to his diabetes management and remains hypertensive.