Hyperosmolar hyperglycemic state in children: case report and review of the literature

Abstract

Hyperosmolar hyperglycemic state (HHS) is a rare complication in children and a life-threatening emergency that presents with a significant increase in blood sugar and hyperosmolarity with or without low ketosis. This study reports the case of a 9-year-old boy with severe HHS due to type 1 diabetes. The patient’s initial serum glucose level was 1600; however, he was discharged in a stable condition. The patient presented many of the known complications of HHS, including decreased level of consciousness, hypovolemic shock, acute kidney injury, and very high serum glucose levels. The patient responded well to invasive fluid resuscitation and insulin administration, was discharged in good general condition without HHS-related complications, and was followed up with insulin therapy. As the prevalence of HHS in children is increasing, it is necessary for physicians to be aware of the unusual manifestations in children, especially children with type 1 diabetes, and to have the ability to diagnose and manage HHS and differentiate it from diabetic ketoacidosis.

Ischemic-Hemorrhagic Stroke in New Onset Type 1 Diabetes Mellitus with Diabetic Ketoacidosis in a Two-Year-Old Toddler: The First Reported Case in Indonesia

“…The diagnosis of hyperosmolar hyperglycemic state (HHS) in this patient can be excluded; at the presentation, the patient might be in hyperosmolar DKA due to hyper-glycemia with a random blood glucose of >600 mg/dL on the first day of hospitalization and Kussmaul respiration [26].…”

Pediatric Hyperglycemic Hyperosmolar Syndrome: A Comprehensive Approach to Diagnosis, Management, and Complications Utilizing Novel Summarizing Acronyms

“…However, recent literature suggests an increasing incidence of HHS in younger, non-obese, and insulin-dependent diabetic patients. Male predominance, a poor social health network, and a positive family history of type 2 diabetes have been reported as risk factors [10]. The ingestion of large volumes of sugar-rich fluids, patients on diabetogenic medications including long-term systemic steroids, L-asparaginase, tacrolimus, growth hormone, and atypical antipsychotics, in addition to cystic fibrosis, have been identified as tangible triggers of HHS in some patients [11,12].…”

“…In DKA, the catabolic mechanism leads to an elevation in ketone bodies composed of acetone, acetoacetic acid, and beta-3-hydroxybutyrate, whereas HHS lacks significant ketoacidosis. The relatively longer period of symptomatic hyperglycemia in HHS produces an extracellular osmotic gradient, shifting fluids out of the cells and precipitating osmotic diuresis; coupled with poor fluid intake, there is an exacerbation of the negative fluid balance, resulting in extreme dehydration and severe hyperosmolar hyperglycemia without significant ketoacidosis [10]. This represents the main distinguishing difference between HHS and DKA.…”

Hyperosmolar Hyperglycaemic State: A Life-Threatening Complication of Type 2 Diabetes Patients

“…They have tried to investigate how to make the diagnosis and also they have recommended treatment of this condition among children (Ng & Edge, 2017). Iraj Shahramian and his coworkers have shown that HHS is a rare complication in children with DM that shows itself with a triad: hyperglycaemia, typically greater than 600 mg/dl; hyperosmolality, serum osmolality greater than 330 mOsm/l; and mild metabolic acidosis; pH greater than 7.2; which is a life-threatening emergency with a mortality rate of 10-50% (Shahramian et al, 2022). Haralampos J. Milionis and Moses S. Elisaf have provided an outline of the diagnostic approach of patients with manifestations of HHS and discuss the contemporary therapeutic recommendations.…”