DIABETES - patientfall

Patientfall1

This Week's Case:

You are asked to see a comatose 75-year-old woman recently admitted to the hospital because of these extraordinary lab values: serum sodium = 199 mEq. and serum glucose = 940 mg. The patient is a widow who has spent the past three years in a nursing home because of progressive senility of unknown cause. She also suffers from hypertension which is well-controlled on inderal and thiazides. One week ago, she developed fever, non-productive cough, and weakness preventing her from feeding herself, necessitating tube feedings. Two days later, she was started on IM penicillin but made no response. A daughter-in-law who accompanied the patient to the hospital knew little about her past history. She did, however, state that the patient, though not known to be diabetic, had been excessively thirsty and urinating a lot in recent weeks.

Make a differential diagnosis:

Primary DX

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Physical Exam

On physical exam, BP = 85/50, pulse = 100 and regular. Temp. = 101 degrees F. (rectally) and respirations = 22. The patient is extremely dehydrated with a shriveled tongue, sunken eyeballs, and poor skin turgor. She is comatose, but responds to painful stimuli. There are no skin lesions or rashes. The fundi could not be visualized; HEENT exam was otherwise negative. Heart, abdomen and extremities are unremarkable. A limited neurological exam reveals no definite neck stiffness nor focal findings.

Modify your differential diagnosis:

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Labs & Studies Request For
Please select the labs you would like to order:

Serum chloride

WBC

Triglycerides

Hemoglobin

Serum bicarbonate

Serum creatinine

Urinalysis

Serum potassium

Cholesterol

Serum acetone

B.U.N.

Labs & Studies Results

Modify your differential diagnosis:

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Additional Information

Other blood chemistries = normal except for LDH = 600
Chest X-ray shows a bilateral pneumonia. EKG shows a sinus tachycardia and left ventricular strain pattern. Blood and urine cultures both grew pseudomonas.

Modify your differential diagnosis:

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Diagnosis

The correct diagnosis is

1. Pseudomonas pneumonia and septicemia
2. Hyperglycemic, hypersmolar, non-ketotic coma
3. Hypothalamic abscess (pseudomonas) with acute diabetes insipidus.

Because of the progressive osmole-driven dehydration, serum sodium levels of 170-180 mEq can be seen with hyperglycemic coma, but a sodium of 199 may well be a world’s record. An early therapeutic dilemma was how rapidly to correct this patient’s extreme fluid deficit. With a CVP catheter is place, we elected to give her 24 liters of hypotonic or normal saline over the first 24 hours, along with small, incremental amounts of insulin plus potassium, heparin, cephalosporin and aminoglycoside antibiotics. The patient died four days later and necropsy revealed the pneumonia and hypothalmic abcess, but only minimal cerebral edema. First described in 1957, the entity of hyperglycemic, hypersmolar, non-ketototic coma remains a medical emergency. This type of coma carries a mortality rate of 20-50% even with aggressive management. The main reason for this is that many of these patients, such as this one, are neglected, tube-fed nursing home "specials". With progressive dehydration comes hemoconcentration, hypotension, drug-resistant seizures, and renal failure -- all contributing to multiple thromboses, the usual causes of death. Apart from deficient fluid intake, certain drugs, such as glucocorticoids and intravenous dilantin, often given together in head injury patients, can precipitate the condition. The absence of significant keto-acidosis in these patients is not altogether clear, though it has been shown many times that their free fatty acid levels are much lower than those in diabetic keto-acidosis -- possibly due to dehydration suppressing the fat-mobilizing hormones of the pituitary and a selective action of available insulin on ketone precursors in the liver. In addition to their propensity to thrombose, a major danger in the treatment of these patients is lowering the blood glucose too rapidly and producing cerebral edema. In this patient, the extreme elevation of her serum sodium and serum osmolarity (480 mOs) made us suspect an element of diabetes insipidus, though we thought this might be on the basis of infarction, not abcess.

Learning Points:

1. A major cause of the high mortality rate in hyperglycemic, hypersmolar coma is that patients arrive at the hospital too dehydrated and too late.

2. Approximately 70% of patients with hyperglycemic, non-ketotic coma give no previous history of diabetes.

3. Although rare, a hypothalmic or pituitary abscess can produce diabetes insipidus, especially when an aggressive infection is present elsewhere.

Hyperglycemic Hyperosmolar Nonketotic Syndrome med bild

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References: Schwartz, T.B. and Apfelbaum, R.I.: Hyperglycemic, Hypersmolar, Non-ketotic Coma.
Yearbook of Endocrinology, 1965, Yearbook Medical Publishers, Inc.