ILLUSTRATIVE CASE
Hyperosmolar Hyperglycemic State Without Ketosis in a Toddler With Type 1 Diabetes Ibrahim M. Alharfi, MD,*Þ Ram Singh, MBBS, FRCPC,* Cheril Clarson, BM BS, FRCPC,* and Jennifer R. Foster, MD, FRCPC*
Abstract: We present a thin toddler whose initial presentation with type 1 diabetes was hyperglycemic hyperosmolar syndrome without diabetic ketoacidosis after ingestion of copious quantities of high-sugar beverages. Increasing consumption of high-sugar beverages may make this presentation of type 1 diabetes mellitus more common. Emergency care physicians must be aware of this potential clinical constellation in the very young, as management differs significantly from that accepted for diabetic ketoacidosis in children. Key Words: type 1 diabetes, diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma, high-carbohydrate beverages (Pediatr Emer Care 2014;30: 485Y487)
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iabetic coma syndromes exist along a continuum, from diabetic ketoacidosis (DKA) with normal osmolality to hyperglycemic hyperosmolar state (HHS) with minimal to no ketosis. The HHS is a rare presentation of childhood diabetes and is extremely uncommon as the first presentation of type 1 diabetes (T1D).1 Diagnostic criteria for HHS usually include plasma glucose concentration 600 mg/dL (33.3 mmol/L) or greater, serum HCO3 of greater than 15 mmol/L, absent to small ketonuria, absent to low ketonemia, effective osmolality 320 mOsm/kg or greater, profound dehydration, and alteration of consciousness.2 However, recent pediatric literature has proposed diagnostic criteria exclusive of altered sensorium,3 and nonketotic acidosis with lowered HCO3 may occur in the presence of significant dehydration resulting in poor perfusion and lactic acidosis.1 As presentation of T1D with HHS is so unusual in children, particularly in young children, the physician must remain vigilant to prevent misdiagnosis of a disease with a high mortality and morbidity if poorly managed.
CASE A 3-year-old, previously healthy boy presented to the emergency department with a 2-week history of cough, rhinorrhea, decreased appetite, and polydipsia. He was given a diagnosis of viral upper respiratory tract infection and was sent home. All symptoms except polydipsia resolved. Three weeks later, he represented to the emergency department with vomiting up to 8 times per day, progressive irritability, polyuria, and polydipsia. Two relatives had type 2 diabetes (T2D), but there was no family history of T1D. The child had consumed large volumes of highsugar beverages; in the 12 hours before the second hospital From the *Department of Pediatrics, Western University, London, Ontario, Canada; and †Department of Pediatric Critical Care, King Fahad Medical City, Riyadh, Saudi Arabia. Disclosure: The authors declare no conflict of interest. Reprints: Jennifer R. Foster, MD, FRCPC, C2-845, Division of Pediatric Critical Care, Children’s Hospital, London Health Sciences Center, London, Ontario, N6A5W9 (e
Hyperosmolar Hyperglycemic State Without Ketosis in a Toddler With Type 1 Diabetes Ibrahim M. Alharfi, MD,*Þ Ram Singh, MBBS, FRCPC,* Cheril Clarson, BM BS, FRCPC,* and Jennifer R. Foster, MD, FRCPC*
Abstract: We present a thin toddler whose initial presentation with type 1 diabetes was hyperglycemic hyperosmolar syndrome without diabetic ketoacidosis after ingestion of copious quantities of high-sugar beverages. Increasing consumption of high-sugar beverages may make this presentation of type 1 diabetes mellitus more common. Emergency care physicians must be aware of this potential clinical constellation in the very young, as management differs significantly from that accepted for diabetic ketoacidosis in children. Key Words: type 1 diabetes, diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma, high-carbohydrate beverages (Pediatr Emer Care 2014;30: 485Y487)
D
iabetic coma syndromes exist along a continuum, from diabetic ketoacidosis (DKA) with normal osmolality to hyperglycemic hyperosmolar state (HHS) with minimal to no ketosis. The HHS is a rare presentation of childhood diabetes and is extremely uncommon as the first presentation of type 1 diabetes (T1D).1 Diagnostic criteria for HHS usually include plasma glucose concentration 600 mg/dL (33.3 mmol/L) or greater, serum HCO3 of greater than 15 mmol/L, absent to small ketonuria, absent to low ketonemia, effective osmolality 320 mOsm/kg or greater, profound dehydration, and alteration of consciousness.2 However, recent pediatric literature has proposed diagnostic criteria exclusive of altered sensorium,3 and nonketotic acidosis with lowered HCO3 may occur in the presence of significant dehydration resulting in poor perfusion and lactic acidosis.1 As presentation of T1D with HHS is so unusual in children, particularly in young children, the physician must remain vigilant to prevent misdiagnosis of a disease with a high mortality and morbidity if poorly managed.
CASE A 3-year-old, previously healthy boy presented to the emergency department with a 2-week history of cough, rhinorrhea, decreased appetite, and polydipsia. He was given a diagnosis of viral upper respiratory tract infection and was sent home. All symptoms except polydipsia resolved. Three weeks later, he represented to the emergency department with vomiting up to 8 times per day, progressive irritability, polyuria, and polydipsia. Two relatives had type 2 diabetes (T2D), but there was no family history of T1D. The child had consumed large volumes of highsugar beverages; in the 12 hours before the second hospital From the *Department of Pediatrics, Western University, London, Ontario, Canada; and †Department of Pediatric Critical Care, King Fahad Medical City, Riyadh, Saudi Arabia. Disclosure: The authors declare no conflict of interest. Reprints: Jennifer R. Foster, MD, FRCPC, C2-845, Division of Pediatric Critical Care, Children’s Hospital, London Health Sciences Center, London, Ontario, N6A5W9 (e
