A Case of Hyperosmolar Hyperglycemic State Caused by Ischemic Pancreatitis

Erika Leung, MD*; Keith W. Murdock, MD; Richard W. Lustig, DO; Heath G. Wilt, DO

University of Missouri-Kansas City; Department of Internal Medicine; St. Luke’s Hospital; Kansas City, Missouri, USA

*Corresponding author:  Erika Leung, MD. University of Missouri-Kansas City; Department of Internal Medicine; St. Luke’s Hospital; Kansas City, Missouri, USA.  E-mail: Erika.leung@mail.mcgill.ca

Published: September 20, 2014.

Abstract: 

Background: The hyperosmolar hyperglycemic state (HHS) is a dangerous complication that can arise with diabetes mellitus. Emergent treatment is necessary to reinstate hemodynamic stability, as mortality rates for HHS are exceptionally high and can have multiple complications. 

Case Report: A 42-year-old female presented unresponsive to the emergency department. Upon arrival, the patient’s examination was consistent with hypovolemia and tachycardia.  Review of systems included a one-week history of nausea and vomiting. The patient had stopped all of her medications one year prior, only restarting metformin one week prior to admission. Her presenting systolic blood pressure was 119 mmHg before she developed respiratory failure secondary to a poor mental state. The presenting blood sugar level was 1263 mg/dL, and ketones were not detected in her urine. The patient recovered from her HHS and was discharged in a stable condition.

Conclusion: This case study postulates that the patient’s excessive nausea and vomiting led to pancreatitis secondary to ischemia, which induced a HHS. This is important because hyperglycemia superimposed on any ischemic insult can increase the risk of multiorgan failure, as with our patient.  Thus, recognition and management of resulting complications needs to be emergent.

Keywords: 
diabetes mellitus; sepsis, ischemia; hyperglycemia.
References: 
  1. Davis SN, Umpierrez GE. Diabetic ketoacidosis in type 2 diabetes mellitus--pathophysiology and clinical presentation. Nat Clin Pract Endocrinol Metab 2007; 3(11): 730-1.
  2. Chen HF, Wang CY, Lee HY, See TT, Chen MH, Jiang JY, et al.  Short-term case fatality rate and associated factors among inpatients with diabetic ketoacidosis and hyperglycemic hyperosmolar state: a hospital-based analysis over a 15-year period. Intern Med 2010; 49(8): 729-37.
  3. Stoner GD. Hyperosmolar hyperglycemic state. Am Fam Physician 2005; 71(9): 1723-30.
  4. Matz R. Management of the hyperosmolar hyperglycemic syndrome. Am Fam Physician 1999; 60(5): 1468-76.
  5. MacIsaac RJ, Lee LY, McNeil KJ, Tsalamandris C, Jerums G. Influence of age on the presentation and outcome of acidotic and hyperosmolar diabetic emergencies. Intern Med J 2002; 32(8): 379-85.
  6. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001; 24(1): 131-53.
  7. Salpeter S, Greyber E, Pasternak G, Salpeter E. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus." Cochrane Database Syst Rev 2003; (2):CD002967.
  8. Chan NN, Brain HP, Feher MD. Metformin-associated lactic acidosis: a rare or very rare clinical entity? Diabet Med 1999; 16(4): 273-81.
  9. Lalau JD. Lactic acidosis induced by metformin: incidence, management and prevention. Drug Saf 2010; 33(9): 727-40.

The fully formatted PDF version is available.          

Download Article

Int J Biomed. 2014; 4(3):159-161. © 2014 International Medical Research and Development Corporation. All rights reserved.