A middle aged man is found down by EMS with a GCS 5. His neighbor reports that the patient was "feeling sick for several days and hadn't been seen." He is intubated in the emergency department for protection of his airway. Exam shows decreased skin turgor and dry oral mucosa. ABG shows pH 7.32, PaCO2 43mmHg, PaO2 240mmHg. A chemistry panel shows sodium 130, potassium 5, chloride 100, bicarbonate 19, BUN 40, Cr 1.4, and a serum glucose >1000mg/dL. CBC shows WBC 18, Hct 48, Plts 200. Urine dipstick is positive for leukocyte esterase and nitrites, negative for everything else. Urine culture grows out gram negative rods.
Challenge: What's the diagnosis?
Image of insulin in the public domain, from Wikipedia.
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PE shows dehydration signs and severe changes in alertness.. Lab shows decreased pH, slightly decreased HCO3- means compensated metabolic acidosis, with consequent K+ on borderline high. Combined with skyrocket glucose level, this means the man is a diabetic with URI, severe infection increase stress hormones, which could lead to decrease insulin--which he's taking regularly most likely-- sensitivity, and boom, hyperosmolar hyperglycemic syndrome.
yes - good explanation!
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Honk If You Like Electrolytes
This is a hyperosmolar hyperglycemic state, characterized by little or no ketoacid accumulation and a dramatic glucose level. Coma is common, serum osmolality can reach 380mosm/kg, and precipitating factors include infection, discontinuation of insulin, dehydration, MI, pancreatitis, and CVA. Symptoms include polyuria, polydipsia, weight loss, and neurologic changes.
Source: UpToDate.
Follow on Question if I may; How do these values differ from DKA, given the vignette simply lacking ketones in the Dipstick should not be sufficient for the diagnosis...
Good question - often these syndromes can be confused, and certainly this case could possibly be DKA or a mixed picture (which happens).
From UpToDate, a hyperosmolar hyperglycemic state often presents with a profound hyperglycemia (>600), though DKA can occasionally present with high values. HHS does not have a profound acidemia or anion gap seen in DKA. Urine and serum ketones can be present but are not as high. Effective serum osmolality in HHS is always high whereas it is variable in DKA.
Both syndromes should be in the differential diagnosis, but here, my intention was hyperosmolar hyperglycemic state.
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