Case history #1
A 72-year-old man is brought to the emergency department from a nursing home for progressive lethargy. The patient has a history of hypertension complicated by a stroke 3 years previously. This has impaired his speech and rendered him wheelchair bound. He also has a schizothymic disorder for which he was started recently on clozapine. On presentation, he is disoriented to time and place and febrile with a temperature of 101°F (38.3°C). Vital signs include a BP of 106/67 mmHg, heart rate of 106 beats per minute, and a respiratory rate of 32 breaths per minute. Initial laboratory workup reveals a serum glucose of 950 mg/dL, a serum sodium of 127 mEq/L, BUN of 59 mg/dL, and a serum creatinine of 2.3 mg/dL. Serum osmolality is calculated as 338 mOsm/kg. Urinalysis reveals numerous white blood cells and bacteria. Urine is positive for nitrates but negative for ketones. Serum is negative for beta-hydroxybutyrate.
Case history #2
A 45-year-old African-American man with a history of type 2 diabetes is admitted directly from clinic for a serum glucose of 970 mg/dL. He was started recently on basal bolus insulin therapy after several years of treatment with oral antiglycemic agents. However, he reports not having filled his insulin prescription owing to its high cost. For the past 2 weeks he has had polyuria, polydipsia, and has lost 5 kg in weight. He has also noted a progressively worsening cough for approximately 3 weeks that is productive of greenish brown sputum. On examination, he is febrile with a temperature of 101.3°F (38.5°C), tachypneic (respiratory rate of 24 breaths per minute), and normotensive. Urinalysis reveals trace ketones but serum beta-hydroxybutyrate is not elevated. Serum bicarbonate is 17 mEq/L and venous pH is 7.32.
Up to 20% of patients admitted with HHS have previously undiagnosed diabetes. Approximately one third of patients with hyperglycemic crises present with a mixed picture of diabetic ketoacidosis and HHS.
Coma is a rare presentation of HHS. Typically, coma is associated with serum osmolality levels >330 to 340 mOsm/kg and is most often due to hypernatremia rather than hyperglycemia.
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