Endocrine Abstracts

Background: Hyperosmolar hyperglycaemic state (HHS) is a life-threatening condition that can be the initial presentation of type 2 diabetes mellitus. This condition is characterized by severe hyperglycaemia, a high serum osmolality and dehydration without accumulation of ketoacids. We report two patients who presented with mixed features of HHS and DKA.

Case 1: An 11-year-old Afro-Caribbean boy with severe developmental delay presented with a 4-week history of polyuria, polydipsia, and drowsiness. Investigations showed severe hyperglycaemia (blood glucose 100 mmol/l), hyperosmolar dehydration (corrected Na 197 mmol/l) metabolic acidosis (pH 7.04, base excess −15.4 mmol/l) and renal failure (urea 40 mmol/l and creatinine 310 μmol/l). HbA1c was 9.8% with blood ketones of 5.4 mmol/l. The patient’s clinical course was complicated by multiorgan failure and rhabdomyolysis requiring ventilation, inotropes, and haemofiltration. He was rehydrated and required i.v. insulin for 2 weeks. GAD and insulin antibodies were negative. There was a strong family history of type 2 DM. His HbA1c normalised (5.4%) 5 weeks later. His diabetes remains diet controlled.

Case 2: 17-year-old girl with Wolf–Hirschhorn syndrome presented in an obtunded state. She had a 2-week history of polyuria, polydipsia and sudden deterioration with drowsiness and agitation. Investigations showed blood glucose >40 mmol/l, corrected Na 187 mmol/l, metabolic acidosis (pH 7.20, base excess of −10.4 mmol/l), and renal failure (urea 30 mmol/l and creatinine 163 μmol/l). HbA1c was 10.5% with moderate ketonuria (3+). She required high dependency care and received i.v. insulin for 2 days and her hypernatraemic dehydration resolved slowly over the next 3 days. Her antibodies were negative. She was discharged 2 weeks on dietary treatment alone.

Conclusion: Children with type 2 diabetes can present with features of HHS and DKA. Learning difficulties and co-morbidities may lead to a delay in presentation and more severe illness. HHS can result in profound hyperglycaemia, hypernatraemia, and severe dehydration and may require intensive care.