Aggressive Fluid Resuscitation in Severe Pediatric Hyperglycemic Hyperosmolar Syndrome: A Case Report

Recent trends indicate a rising percentage of type two diabetes in the under eighteen population, with a prevalence of 0.22 cases per 1000 youth [1] amongst the American population. Hyperglycemic hyperosmolar syndrome (HHS), a rare pediatric complication of diabetes mellitus (DM), is characterized by the triad of hyperglycemia (typically > 600？mg/dL), hyperosmolality (serum osmolality >330？mOsm/L), and a mild metabolic acidosis (pH > 7.2). It portends a very poor prognosis, with mortality rates of between 10–50% in adults [2]. In children, similar mortality rates have been observed [3], although most of the literature is limited to case series and reports. In adults, documented major complications include thrombosis, rhabdomyolysis, renal failure, and irreversible cardiac arrhythmias [4]. A formal distinction between HHS and diabetic ketoacidosis (DKA) exists, with DKA typically presenting with lower levels of hyperglycemia, ketosis, and more significant metabolic acidosis, although these two illnesses are more likely on the spectrum of decompensations related to diabetes [2]. HHS is classically associated with type 2 DM, although it has also been increasingly reported in type 1 DM [5, 6] as well. DKA has a much better prognosis, with pediatric mortality rates below 1% [7], and cerebral edema being the major cause of death.We present a case of an adolescent girl with newly diagnosed HHS and review some of the current literature on the presentation and management of pediatric HHS.The patient was a previously healthy 12 year-old African American female who presented to the emergency room with a chief complaint of altered mental status. She had been having upper-respiratory symptoms for the preceding 4–5 days, with diarrhea and vomiting for three days. She was thirsty, supplementing her diet with milkshakes and smoothies. The night prior to presentation, she awoke somewhat disoriented, which the parents assumed was a bad dream. On the day of presentation, the patient b