LAUSR

INTRODUCTION: Diabetic Ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are serious conditions associated with diabetes mellitus (DM) Concurrent DKA and HHS are rare in children, and so far, few cases are reported We report an adolescent female with new-onset Type 1 DM presented as mixed DKA and severe HHS METHODS: A 14-year-old female, bodyweight of 22 kg (BMI for age <1 percentile) presented with 4 weeks of polyuria, polydipsia, and lethargy with poor oral intake for 2 days Past medical history includes developmental delay, spastic quadriplegia, epilepsy, and congenital hydrocephalus with ventriculoperitoneal shunt On admission, she was somnolent with severe dehydration and decompensated shock Laboratory studies on presentation included: serum glucose 1188 mg/dL, serum osmolarity 428 mOsm /kg, venous blood gas pH 7 09, bicarbonate 15 mEq/L, base excess negative 15 mEq/L, serum sodium 160 mEq/L (corrected sodium 177 mEq/L), ketonuria +1, glycosylated hemoglobin 13 7%, BUN 49 mg/dL, and serum creatinine 1 7 mg/dL Liver function tests, coagulation profile, cortisol, and adrenocorticotrophic hormone levels were normal COVID-19 PCR test was negative Her blood workup was consistent with HHS and DKA She received fluid resuscitation (60 ml/kg of ringer lactate) and pressor therapy, resulting in a quick resolution of shock Continuous insulin drip decreased within 6 hours of hospitalization due to the correction of acidosis and decreasing glucose levels Fluid therapy with 0 45% normal saline was used at twice maintenance Within 48 hours of hospitalization, hyperosmolarity was corrected, and her sensorium improved By day 3, nasogastric feeds were established She had elevated GAD insulin antibodies and diagnosed with type 1 DM She was discharged on subcutaneous insulin therapy RESULTS: Children with cognitive impairment can be at risk for severe dehydration if they have an inability to hydrate independently and have poor oral intake In this case, severe hyperglycemia in the setting of new-onset type 1 DM resulted in HHS with moderate DKA DKA resolved quickly, although the hyperosmolar state was prolonged due to severe hypernatremia Early differentiation of these two entities and meticulous fluid management improves the outcome