Hyperglycaemic hyperosmolar state: first presentation of type 1 diabetes mellitus in an adolescent with complex medical needs

Abstract

This is a case of hyperglycaemic hyperosmolar state (HHS) as first presentation of type 1 diabetes mellitus in a 14-year-old girl with background complex medical needs. She presented with marked hyperglycaemia (56 mmol/L) without significant ketonaemia (2.6 mmol/L) and serum hyperosmolality (426 mOsm/kg). Managing her profound hypernatraemic (>180 mmol/L) dehydration was challenging but resulted in good outcome. Paediatric patients with HHS will likely be treated with the diabetes ketoacidosis (DKA) protocol because of perceived rarity of HHS leading to inadequate rehydration and risk of vascular collapse. Hence, emphasis on the differences in the management protocols of DKA and HHS is paramount. Prompt recognition and adequate management are crucial to avert complications. The undesirable rate of decline of hypernatraemia due to the use of hypotonic fluid was captured in this case. We describe the pivotal role of liberal fluid therapy with non-hypotonic fluids.

Keywords: cerebral palsy; diabetes; fluid electrolyte and acid–base disturbances.

Figure 1

Trend of corrected serum sodium and osmolality in the first 72 hours. *Blood glucose was unrecordably high. **Corrected sodium=measured Na+2[(plasma glucose: 5.6)/5.6] mmol/L. ***Effective osmolality (mOsmol/kg)=2 X (plasma Na)+plasma glucose+serum urea (all in mmol/L). Red circle: drop in corrected sodium of 11 mmol/L in 12 hours (>0.5 mmol/L/hour).