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A case of unusual presentation of hyperosmolar hyperglycemic state (hhs)

Author: 
Radhika Bulusu, Jeevana Kurugoda, Indranil Das and Shastry, V.G.R.
Subject Area: 
Health Sciences
Abstract: 

Introduction: Hyperglycaemia is an important diagnostic differential and has been reported to cause focal neurological deficits masquerading as stroke. Discussion of hyperglycaemia as a stroke mimic has been sparse in the era of discussion weighted imaging, but remains an important mimic. Objective: To create awareness that hyperglycaemia should be considered in patients presenting to the Ed with focal neurological symptoms. Case Presentation: A 98 Year old Female was brought to the ED with C/o Altered Sensorium, one episode of seizure, Right sided Upper and Lower Limb Weakness, Aphasia Since around 30 minutes prior to arrival to the ED. Patient is known case of Hypertension, Diabetes Mellitus Type II, and Coronary Artery Disease – Post – PTCA, Non – Compliant to medications. On examination, patient had a GCS of E4V1M4, Pupils werebilaterally 2mm and sluggishly reacting, her random blood glucose was 719 mg/dL. Her CNS examination revealed the power in her right Upper and Lower Limbs was 0/5, whereas herleft upper and lower limbs had a power of 5/5, deep tendon reflexes –on the Right Side were Muteand brisk on the left side. Plantar reflex onright side was Mute and left side was extensor. Patient’s Blood Gas Analysis, revealed Lactic Acidosis. Urine Ketones was Negative. The patient was found to have a High Serum Osmolality of 315mmol/Kg. In view of clinical findings, patient was suspected to have a Hyperosmolar hyperglycaemic state (HHS) with Stroke and as per the Stroke Protocol, Non – Contrast Computed Tomography (NCCT) Brain, followed by MRI Brain was done which was not conclusive of any acute changes. The patient was immediately started on Intravenous Fluids, for management of HHS, along with Insulin infusion. Neurology Consultation, Endocrinology and Cardiology Consultation were taken. Patient’s Neurological Status Improved after 2 hours of management in the ED.She was admitted in the Intensive Care Unit (ICU).Patient improved over the course of her stay in the hospital and was discharged on the 5th day with follow-up advice. Conclusion: In conclusion, our patient had a hyperglycaemic hyperosmolar state (HHS) induced focal neurological deficit, which presented as transient ischaemic attack (TIA). We would state that in a patient presenting with focal neurological deficit and hyperglycemia, hyperglycaemic hyperosmolar state (HHS) induced focal neurological deficit should be considered as a differential diagnosis.

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