Altered mental status presenting to the pediatric emergency department

Case Report Introduction Hyperosmolar hyperglycemic state (HHS) represents a syndrome of acute diabetic decompensation characterized by marked hyperglycemia, hyperosmolality, dehydration and decreased mental status that may progress to coma About 20% of patients have no known history of type 2 diabetes Case A 15 yo male presented to the emergency department with altered mental status Mom reported that he had malaise, polydipsia and polyuria for 1 week and 2 days of right flank pain She denied fever, cough, headache, diarrhea, vomiting and rash Prior to arrival he was found unresponsive with urinary incontinence Vital signs: HR 136 RR 20 BP 140/62 T 101 2 90% on RA Responsive only to deep sternal rub HEENT: PERRL Respiratory: CTAB Cardiac: Tachycardic, gallop present Skin: Cool periphery, no edema, or petechiae Abdomen: soft, NTND Neuro: No obvious focal deficit Labs: VBG: pH 7 18, pCO2 49 9, pO2 59, HCO3 19, Lactic acid 7 5, Glucose >700 Lipid Panel: normal CMP: Na 131, K 3 4,Bicarb 9, Bun 42,Cr 2 93, Albumin 5 0, liver enzymes normal, Phos 2 3, Mg 3 55, Ca 10 9, glucose 2238, lipase 1600 CT head revealed cerebral edema, MRV negative for dural sinus thrombosis COVID PCR positive, VRP negative Hospital course: ED: Patient was given 2L of LR boluses, mannitol and insulin drip was started 2 LPM of supplemental oxygen was given for hypoxia to 88% ICU: Patient was intubated for acute respiratory failure and shock Received >8L volume and was started on epinephrine, vasopressin and milrinone He was given steroids for fluid resistant shock, vancomycin, cefepime and flagyl Echocardiogram showed hyperdynamic function Elevated ferritin, ddimer and inflammatory markers were concerning for multisystem inflammatory syndrome (MIS-C), so he received IVIG Became oliguric with AKI requiring dialysis Discussion Associated diseases in HHS are gram-negative pneumonia, GI bleeding and gram negative sepsis There is insufficient data on SARS-CoV-2 and HHS Case reports indicate that MIS-C may present with clinical entities as varied as appendicitis, pseudotumor and encephalopathy We present a unique case of HHS and MIS-C Pediatric HHS has a higher incidence of fatal cerebral edema and warrants early recognition and further investigation as our clinical understanding of MIS-C continues to evolve