Extreme hyperosmolarity and severe ketoacidosis in a child with type 1 diabetes mellitus at onset safely treated with current guidelines

Excerpt

Type 1 diabetes mellitus (T1DM) is an autoimmune disorder characterized by the destruction of pancreatic beta cells by autoantibodies resulting in low or no production of endogenous insulin. The incidence of T1DM is extremely variable depending on the countries, and it is progressively growing [1]. Ketoacidosis (DKA) is present at diagnosis in 15–70% of patients affected by T1DM and is more frequent in children younger than 2 years of age, in case of delayed diagnosis, in some ethnic minorities and in children with poor access to medical care for socio-economic reasons [1]. DKA is defined by the presence of hyperglycaemia (blood glucose > 200 mg/dL), venous pH < 7.3 or serum bicarbonate < 15 mmol/L, ketonemia (blood β-hydroxybutyrate ≥ 3 mmol/L) or moderate or large ketonuria. Clinically, it shows through dehydration, tachycardia, tachypnea, sighing (Kussmaul) respiration, nausea, vomiting, abdominal pain and confusion state up to coma [1]. The hyperglycaemic hyperosmolar state (HHS) is an uncommon condition in children, and it usually occurs in an obese adolescent with type 2 diabetes mellitus (T2DM). Criteria to define HHS are hyperglycaemia (blood glucose > 600 mg/dL), venous pH > 7.25 (arterial pH > 7.3), bicarbonate > 15 mmol/L, small ketonuria and absent or mild ketonemia, serum osmolarity > 320 mOsm/kg, altered mental status and severe dehydration [1]. HHS rarely represents the onset manifestation of T1DM [2]. Some cases of T1DM with an initial manifestation of a mixed state with both conditions (DKA-HHS) are described in the literature [3]. …