Afasia como debut de estado hiperosmolar hiperglicémico. Caso clínico / Aphasia as the presenting symptom of a hyperglycemic hyperosmolar state. Case report

Neurological manifestations such as seizures, disorders of consciousness and abnormal movements such as hemichorea and hemiballismus can be the presenting symptoms of hyperglycemic hyperosmolar states. Exceptionally, focal signs as hemiparesis or aphasia are described. We report a 66-year-old man, presenting with nonfluent aphasia and right subtle hemiparesis. The computed tomography, computed tomography angiography and brain magnetic resonance did not show acute ischemic lesions or obstruction of arterial vessels. The initial laboratory evaluation disclosed a blood glucose of 936 mg/dL, a plasma osmolality of 331 mOsm/Kg, and positive plasma ketones. After the treatment of hyperglycemia and hyperosmolality, focal symptoms subsided.

Outcome of hyperglycemic emergencies in a tertiary hospital, South East, Nigeria

Background: Hyperglycemic emergency (HE) is typically represented by diabetic ketoacidosis, (DKA) and hyperosmolar hyperglycemic state (HHS). It is a common cause of hospitalization due to diabetes mellitus (DM) and is associated with considerable mortality. In South East Nigeria, there is a paucity of studies on the treatment outcome of HE, hence the need for this study. Objective: The aim and objective of the study were to determine the outcome of treatment of adult persons living with diabetes managed for HE at Federal Medical Centre (FMC), Umuahia. Materials and Methods: This was a prospective study in which 110 consecutive adult patients managed for HE at FMC, Umuahia, were recruited. Data obtained included a total number of medical and diabetic admissions within the study period. For participants that met the inclusion criteria for the study, their bio­data, blood pressures, level of consciousness at presentation or while being treated, random plasma glucose, plasma electrolytes, urea, creatinine, and plasma 3­beta­hydroxybutyrate were noted and/or measured. Similarly, urine sample was collected from each participant for analysis (glucose, protein, and ketone). The outcome measures were patient's survival, hospitalization duration, and death. Analysis of data was done using SPSS 20.0 and the level of statistical significance was set at P < 0.05. Results: Of the 110 participants recruited, there were 46 (41.8%) males and 64 (58.2%) females. HE constituted 15.6% of the total medical admissions within the study period with a mortality of 10%. DKA and mixed form of HE were the predominant patterns in the study. While hospitalization duration was variable, no female participant was discharged against medical advice. Conclusion: The study showed that HE is a frequent acute complication of DM in this region ofNigeria and that HE typically presents as DKA and mixed form. Hospitalization for HE had a variable duration with a significant mortality

Trends in Hyperglycemic Crisis Hospitalizations and in- and out-of-Hospital Mortality in the Last Decade Based on Korean National Health Insurance Claims Data

BACKGROUND: Hyperglycemic crisis is a metabolic emergency associated with diabetes mellitus. However, accurate epidemiologic information on cases of hyperglycemic crisis in Korea remains scarce. We evaluated trends in hyperglycemic crisis hospitalizations and in- and out-of-hospital mortality in Korea. We also predicted future trends. METHODS: We extracted claims data with hyperglycemic crisis as the principal diagnosis from the National Health Insurance Service database in Korea from January 2004 to December 2013. We investigated the numbers of claims with hyperglycemic crisis and identified trends in hyperglycemic crisis based on those claims data. We predicted future trends by statistical estimation. RESULTS: The total annual number of claims of hyperglycemic crisis increased from 2,674 in 2004 to 5,540 in 2013. Statistical analysis revealed an increasing trend in hyperglycemic crisis hospitalizations (P for trend <0.01). In contrast, the hospitalization rate per 1,000 diabetes cases showed a decreasing trend (P for trend <0.01) during this period. The mortality rate per 1,000 diabetes cases also showed a decreasing trend (P for trend <0.0001). However, no distinct linear trend in the case-related fatality rate at <60 days over the last decade was observed. The predicted number of annual claims of hyperglycemic crisis will increase by 2030. CONCLUSION: The number of hyperglycemic crisis hospitalizations in Korea increased in the last decade, although the hospitalization rate per 1,000 diabetes cases and mortality rate decreased. Also, the predicted number of annual claims will increase in the future. Thus, it is necessary to establish long-term healthcare policies to prevent hyperglycemic crisis.

Short-term Effect of Ambient Air Pollution on Emergency Department Visits for Diabetic Coma in Seoul, Korea / 예방의학회지

OBJECTIVES: A positive association between air pollution and both the incidence and prevalence of diabetes mellitus (DM) has been reported in some epidemiologic and animal studies, but little research has evaluated the relationship between air pollution and diabetic coma. Diabetic coma is an acute complication of DM caused by diabetic ketoacidosis or hyperosmolar hyperglycemic state, which is characterized by extreme hyperglycemia accompanied by coma. We conducted a time-series study with a generalized additive model using a distributed-lag non-linear model to assess the association between ambient air pollution (particulate matter less than 10 μm in aerodynamic diameter, nitrogen dioxide [NO2], sulfur dioxide, carbon monoxide, and ozone) and emergency department (ED) visits for DM with coma in Seoul, Korea from 2005 to 2009. METHODS: The ED data and medical records from the 3 years previous to each diabetic coma event were obtained from the Health Insurance Review and Assessment Service to examine the relationship with air pollutants. RESULTS: Overall, the adjusted relative risks (RRs) for an interquartile range (IQR) increment of NO2 was statistically significant at lag 1 (RR, 1.125; 95% confidence interval [CI], 1.039 to 1.219) in a single-lag model and both lag 0-1 (RR, 1.120; 95% CI, 1.028 to 1.219) and lag 0-3 (RR, 1.092; 95% CI, 1.005 to 1.186) in a cumulative-lag model. In a subgroup analysis, significant positive RRs were found for females for per-IQR increments of NO2 at cumulative lag 0-3 (RR, 1.149; 95% CI, 1.022 to 1.291). CONCLUSIONS: The results of our study suggest that ambient air pollution, specifically NO2, is associated with ED visits for diabetic coma.

Hyperglycemic hyperosmolar state associated with invasive rhino-orbital aspergillosis in a patient with end-stage renal disease

No abstract available.

Prognostic Factors in Patients Hospitalized with Diabetic Ketoacidosis

BACKGROUND: Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, acidosis, and ketonemia. This condition is life-threatening despite improvements in diabetic care. The purpose of this study was to evaluate the clinical and biochemical prognostic markers of DKA. We assessed correlations in prognostic markers with DKA-associated morbidity and mortality. METHODS: Two hundred and seventy patients that were hospitalized with DKA over a period of 2 years were evaluated clinically and by laboratory tests. Serial assays of serum electrolytes, glucose, and blood pH were performed, and clinical outcome was noted as either discharged to home or death. RESULTS: The analysis indicated that significant predictors included sex, history of type 1 diabetes mellitus or type 2 diabetes mellitus, systolic blood pressure, diastolic blood pressure, total leukocyte count, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, blood urea nitrogen, serum creatinine, serum magnesium, serum phosphate, serum osmolality, serum glutamic oxaloacetic transaminases, serum glutamic pyruvic transaminases, serum albumin, which were further regressed and subjected to multivariate logistic regression (MLR) analysis. The MLR analysis indicated that males were 7.93 times more likely to have favorable outcome compared with female patients (odds ratio, 7.93; 95% confidence interval, 3.99 to 13.51), while decreases in mean APACHE II score (14.83) and serum phosphate (4.38) at presentation may lead to 2.86- and 2.71-fold better outcomes, respectively, compared with higher levels (APACHE II score, 25.00; serum phosphate, 6.04). CONCLUSION: Sex, baseline biochemical parameters such as APACHE II score, and phosphate level were important predictors of the DKA-associated mortality.

Diabetic Ketoacidosis with Hyperglycemic Hyperosmolar State at the Onset of Type 2 Diabetes Mellitus in an Adolescent Male

A hyperglycemic hyperosmolar state is usually associated with type 2 diabetes. It has significant mortality and morbidity and is rare in the pediatric population. We describe a rare case of a 15-year-old boy with type 2 diabetes who presented to the emergency department with a mixed hyperglycemic hyperosmolar state and diabetic ketoacidosis. Excessive consumption of high-sugar carbonated drinks may have worsening the initial presentation. The patient recovered without any complications. We highlight the fact that gradual correction of osmolarity and sodium is important to avoid cerebral edema despite severe dehydration.

Expressive aphasia as the manifestation of hyperglycemic crisis in type 2 diabetes

No abstract available.

Central pontine myelinolysis in the hyperosmolar hyperglycaemic state

To report a rare association of central pontine myelinolysis [CPM] with hyperosmolar hyperglycaemic state [HHS]. A diabetic female presented with HHS and prolonged severe hypernatraemia. The metabolic derangement was adequately treated with proper correction of both hyperglycaemia and hypernatraemia. Lack of improvement in the presenting confusional state and the development of a fresh neurological deterioration led to the suspicion of CPM that was confirmed with magnetic resonance imaging. She fully recovered after 4 weeks with no specific medical treatment. This case report showed that osmotic demyelination was linked to hypernatraemia and that CPM could result from severe hypernatraemia of HHS

Actualizacón en el manejo de la cetoacidosis diabética y el estado hiperosmolar hiperglucémico en adultos / Treatment updates in diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome in the adult

Introducción: La cetoacidosis diabética y el estado hiperosmolar hiperglucémico son las complicaciones agudas de la diabetes mellitus y constituyen causas frecuentes de ingreso en los hospitales. La patogenia de estas dos patologías difiere en cuanto a la disponibilidad de insulina, el estado de hidratación e incrementos de las hormonas contra reguladoras y por lo tanto la terapia es diferente. Fuentes: Artículos publicados a nivel internacional en relación al tratamiento de dichas patologías en los últimos 10 años. Desarrollo: El tratamiento de la cetoacidosis diabética requiere la administración de insulina, mientras que el estado hiperosmolar hiperglucémico requiere primordialmente de la adecuada terapia hídrica sustitutiva. Sin embargo en ambas situaciones es importante realizar al ingreso una minuciosa valoración clínicay laboratorial a los pacientes para establecer el manejo específico e individualizado en cada caso. Ya que la administración de insulina sin cuantificar previamente los niveles de potasio, selección inadecuada de soluciones isotónicas o hipotónicas para restitución hídrica, descenso acelerado de la osmolaridad plasmática entre otros, pueden poner en peligro la vida del paciente. Conclusión: El éxito de la terapia depende de la estrecha vigilancia clínico laboratorial periódica del paciente y de la capacidad del médico para identificar, tratar y prevenir las complicaciones tales como la hipoglucemia, hipocalemia, edema cerebral, síndrome de distres respiratorio agudo, tromboembolismo y coagulación intravascular diseminada entre otras con un alto grado de mortalidad; en los últimos años se han adoptado nuevas guías de manejo para estas condiciones, las cuales son recopiladas en esta revisión...

Coma hiperosmolar no cetósico, caso clínico / Nonketotic hyperosmolar coma, clinic case

La diabetes mellitus (DM) es una enfermedad compleja que incluye varios síndromes caracterizados por hiperglicemia. A continuación se detalla el caso de un paciente de sexo femenino de 65 años, con diabetes II que desencadena un coma hiperosmolar no cetósico por infección de tracto urinario (ITU). El objetivo de la revisión de este caso es recordar esta patología, y crear un algoritmo diagnóstico terapéutico.

Diabetes mellitus (DM) is a complex illness which includes several syndromes characterized by hyperglycemia. We are detailing the case of a 65-year-old female patient, with diabetes II which triggered a nonketotic hyperosmolar coma because of an infection in urinary tract (IUT). The objective of the check-up in this case is to review this pathology, and to create a therapeutic diagnostic algorithm.

Coma hiperosmolar / Hyperosmolar coma

El coma hiperosmolar, hiperglicémico, no cetoacidótico, o más conocido como hiperosmolar, es un grave trastorno metabólico que puede verse en determinados pacientes diabéticos cuando, a expensas, sobre todo de una hiperglicemia severa, mayor de 500 mg/dL, y en menor grado, de una hipernatremia absoluta. Se origina por el aumento de la osmolaridad plasmática, estableciéndose con un cuadro de deshidratación intensa, tanto intracelular como extracelular, con toma de la conciencia (que puede llegar hasta el coma). En el coma hiperosmolar se destaca la escasa existencia o la ausencia total de la cetoacidosis acompañante. Es característica su elevada mortalidad, cuando el referido coma no es diagnosticado a tiempo o no se aplican las medidas terapéuticas adecuadas(AU)

Hyperosmolar, hyperglycemic, non-ketoacidotic coma, or better known as hyperosmolar, is a serious metabolic disorder that can be seen in certain diabetic patients when, at the expense, especially of severe hyperglycemia, greater than 500 mg / dL, and to a lesser degree , of an absolute hypernatremia. It originates from the increase in plasma osmolarity, establishing itself with a picture of intense dehydration, both intracellular and extracellular, with awareness (which can lead to coma). In hyperosmolar coma, the scarce existence or total absence of the accompanying ketoacidosis stands out. Its high mortality is characteristic, when the referred coma is not diagnosed in time or the appropriate therapeutic measures are not applied(AU)

Coma hiperosmolar associado ao transplante de fígado / Hyperosmolar coma associated with liver transplantation

INTRODUÇÃO: O diagnóstico diferencial dos pacientes inconscientes sempre inclui o coma hiperosmolar hiperglicêmico não-cetótico.RELATO DE CASO: Paciente do sexo feminino, 22 anos, tipo sangüíneo O+, branca, natural e procedente do Recife - PE com queixa de icterícia e astenia há um mês. Ao exame físico, havia icterícia 3+/4+, desnutrição leve (IMC 17,5) e asterixis. Os exames laboratoriais sugeriram hepatite fulminante. Após 12 horas da inclusão na lista de espera pelo transplante, recebeu enxerto de fígado de doador cadáver, mediante o uso de técnica de piggback sem intercorrências. No 10º dia pós-operatório evoluiu com trombose de artéria hepática (TAH), diagnosticada por ultra-som com doppler de artéria hepática. Após 48 horas foi retransplantada sem intercorrências. A partir do 13º dia de pós-operatório, evoluiu com hiperglicemia grave (> 600 mg/dl) e alteração do nível de consciência (9 pontos na escala de coma de Glasgow). Osmolaridade sérica nesse momento igual a 309 mOsm/kgH2O. O nível sérico de tacrolimus nesse dia foi de 11 ng/dl. Coma hiperosmolar hiperglicêmico não-cetótico foi tratado clinicamente por 48 horas. Recebeu alta no 30º dia de pós-operatório do retransplante, sem diabete mellitus.CONCLUSÃO: O coma hiperosmolar é um evento raro no pós-operatório de transplante de fígado e pode modificar a evolução do paciente.

BACKGROUND: The literature described an increased incidence of gastrointestinal stromal tumors (GISTs) in patients with neurofibromatosis type 1. These tumors typically occur in the small intestine, and frequently are multiple. Often the behavior of the tumor in this association is more favorable than in sporadic cases.CASE REPORT: Incidental diagnosis of GIST was done in a patient with neurofibromatosis type 1 during treatment for acute abdomen. Trans-operatively was identified a retrocecal perforated appendicitis and a neoplastic mass in the proximal jejunum. The lesion occupied approximately 70% of the circumference of the organ and had no invasion of adjacent structures. Moreover, there were dozens of small nodules scattered throughout the length of the jejunum and ileum. The pathology revealed malignancy consistent with GIST, with moderate degree of atypia, low mitotic index (<5 / 50) and absence of necrosis. In immunohistochemical analysis, the neoplastic cells were positive for CD-34 and CD-117 (c-KIT), and negative for desmin. After surgery, the use of Imatinib chemotherapy was indicated. After a follow-up period of 12 months, the patient showed no signs of recurrence.CONCLUSION: GISTs should be considered in the presence of abdominal mass and neurofibromatosis type 1, affecting mainly small bowel. Sometimes Imatinib can be administered with good results in the control of the disease.

Regulation of neuropeptide Y, vasoactive intestinal peptide and galanin by insulin in rats

To study the regulation of neuropeptide Y, vasoactive intestinal peptide and galanin by insulin in rats. Experimental study. The study was conducted at the department of Metabolic Medicine Hammersmith hospital, Royal Postgraduate Medical School, London for on year [1996-1997]. Tissue levels of neuro peptide Y [NPY] and vaso intestinal peptide [VIP] decreased of the intestine and pancreas in insulin infused rats. NPY was also decreased significantly in hypothalamus. No significant effect on NPY in brain stem and on VIP in hypothalamus was observed. Galanin decreased significantly in intestine and hypothalamus. Galanin mRNA decreased to 57.7 +/- 8.8 percent of controls [p < 0.05] in intestine and 58.7 +/- 17.7 percent of controls in hypothalamus. Therefore insulin decreased the tissue levels of galanin by inhibiting its mRNA. It is concluded that NPY, VIP and galanin are negatively regulated by insulin. Actions of insulin on endocrine pancreas and central control of glucose homeostasis and food intake by insulin may be partly modulated through changes in these peptides. VIP acts synergistically with glucagon in the development of hyperosmolar coma in NIDDM patients. NPY and galanin increase ketone bodies formation and hyperphagia in diabetics and contribute in the development of diabetic ketoacidosis and obesity

Hyperglycemic Hyperosmolar State in Children with Type 2 Diabetes Mellitus: A Report of Two Cases / 대한소아내분비학회지

Hyperglycemic hyperosmolar state (HHS) is usually associated with type 2 diabetes mellitus (T2DM) with signigicant mortality and morbidity and is rare in pediatric population. The incidence of obesity and T2DM in children and adolescents is increasing at an alarming rate. With increasing rates of T2DM, the incidence of HHS may increase in pediatric population. HHS is characterized by severe hyperglycemia, a marked increase in serum osmolarity and clinical evidence of dehydration. The significance of HHS in children and adolescents remains largely unappreciated. We describe two obese adolescents with hyperglycemic hyperosmolar state at the onset of T2DM.

Complicações hiperglicêmicas agudas no diabetes melito tipo 1 do jovem: [revisão] / Hyperglycemic acute crisis in type 1 diabetes mellitus in youth: [review]

A principal complicação hiperglicêmica no diabetes melito tipo 1 (DM1) é a cetoacidose diabética (CAD). Embora variações nos protocolos possam ocorrer, os princípios básicos que norteiam o tratamento devem ser os mesmos. A recuperação inicial da capacidade circulatória, com a infusão rápida de solução salina na dose de 20 mL/kg, que pode ser repetida, é o ponto de partida para o tratamento. A partir daí, a reposição de volume é relativamente lenta, e o objetivo principal é corrigir gradualmente os distúrbios metabólicos instalados, sem ocasionar variações muito intensas e muito rápidas na osmolalidade, fator de risco para complicações. Atenção ao desenvolvimento de edema cerebral que, uma vez suspeitado, deve ser imediatamente corrigido, sob pena de óbito ou seqüelas neurológicas. A administração de insulina ultra-rápida, por via subcutânea, mostra-se eficaz e simplifica o atendimento do paciente. A CAD é uma situação grave, ainda com alta mortalidade, e seu tratamento deve ser dirigido aos pontos principais que levaram ao quadro clínico, com correções graduais, sob risco de se agravar o quadro.

Diabetic ketoacidosis (DKA) is the main hyperglycemic complication in type 1 Diabetes Mellitus (DM1). The basic principles in treatment have to be followed carefully. The patient with DKA has a very deep volume depletion. To restore the circulatory capacity is the first step. From this point on, the restoration of the lost fluids is slow, around 1 percent per hour, aiming at the correction of the metabolic disturbance already on and avoiding great fluctuations in osmolality, which increases the risk of having complications. Attention to the development of cerebral edema, which, once suspected, deserves an urgent treatment plan, trying to avoid neurologic sequelae or even death. Subcutaneous ultra-rapid insulin has been demonstrated to be efficient and easier to use. As the perfusion gets improved and the levels of insulin increase, the lipolysis is blocked, as well as the generation of ketones and so the acidemia tends to be solved. DKA is still a high-mortality condition. And to be in a hurry frequently leads to neurologic sequelae and even to a fatal outcome.