Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 21

21 - HYPERGLYCEMIC HYPEROSMOLAR SYNDROME CAUSING HYPERCOAGULABILITY AND VENOUS THROMBOEMBOLISM

Friday, Apr 26
12:00 PM – 12:30 PM

Objective : A 50 year old male with no known health problems was brought to the emergency department by his family for evaluation of altered mental status (AMS).  He had experienced polyuria and polydipsia for at least two weeks prior to presentation.  Admission laboratories were notable for a plasma glucose of 1,231 mg/dL, acute renal failure, and elevations of both lactate and beta-hydroxybutyrate.  Hyperglycemic hyperosmolar syndrome (HHS) was diagnosed, and the patient was managed with parenteral fluids and insulin.  AMS and metabolic derangements resolved with treatment of severe hyperglycemia, but tachycardia and mild-to-moderate respiratory distress persisted.  A computed tomography angiogram revealed extensive bilateral pulmonary emboli extending into main, segmental, and subsegmental pulmonary arteries.  Venous Doppler imaging confirmed a left lower extremity deep venous thrombus.  Respiratory distress responded well to tissue plasminogen activator (tPA) and heparin.  Protein C (29%, 77-145) and protein S (31%, 65-123) activities were low, but evaluation for other potential etiologies of hypercoagulability was unremarkable.  The patient was discharged home on insulin and warfarin.


Methods : NA


Results : NA


Discussion : Diabetes mellitus is an important but often overlooked risk factor for venous thromboembolism (VTE).  Hyperglycemia has multiple effects that predispose to VTE including endothelial dysfunction, platelet hyperactivity, increased coagulation factor levels, and decreased fibrinolytic activity.  Reduced activity of both protein C and protein S is well documented in the setting of diabetes.  In a retrospective study of patients admitted to Umeå University Hospital (Sweden), patients with diabetes had an over two-fold higher risk of admission for VTE than non-diabetic individuals.  HHS also significantly increases the risk of VTE.  Proportional hazard modeling of data from the California Patient Discharge Data Set controlling for age, gender, race and hospitalization within 90 days revealed that HHS increased the risk of incident VTE by over 16-fold; only sepsis and acute connective tissue disorders were associated with higher VTE risk.  In the absence of established VTE risk factors such as advanced age, cancer, recent surgery, and prolonged immobilization, HHS appeared to be the etiology of VTE in our patient’s case.


Conclusion : Diabetes mellitus induces a hypercoagulable state that predisposes to both arterial and venous thrombosis.  This case illustrates that HHS is an independent risk factor for VTE, and patients with HHS should be evaluated for VTE promptly when symptoms and signs of venous thrombosis are identified.

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Romana Kanta

Endocrinology Fellow
SIU school of Medicine, Endocrinology division
Springfield, Illinois

I completed internal medicine residency at Jersey Shore University Medical Center (Perth Amboy, NJ). I am currently a first year fellow in the SIU School of Medicine Division of Endocrinology (Springfield, IL).

Nishat Fatima

Endocrinology Fellow
SIU school of Medicine, Endocrinology division

Dr. Fatima is a second year endocrinology fellow in SIU.

Stacey Ward

APRN
SIU school of Medicine, Endocrinology division

Stacey Ward is an advanced practice nurse in the SIU School of Medicine Division of Endocrinology.

Hadoun Jabri

Assistant Professor of Medicine
Division of Endocrinology, SIU School of Medicine

Dr. Jabri is an Assistant Professor of Medicine and Associate Fellowship Program Director in the SIU Division of Endocrinology.

Michael Jakoby

Associate Professor of Medicine and Chief
Division of Endocrinology, SIU School of Medicine
Springfield, Illinois

Dr. Jakoby is the Division Chief and an Associate Professor of Medicine in the SIU School of Medicine Division of Endocrinology.

Romana Kanta

Endocrinology Fellow
SIU school of Medicine, Endocrinology division
Springfield, Illinois

I completed internal medicine residency at Jersey Shore University Medical Center (Perth Amboy, NJ). I am currently a first year fellow in the SIU School of Medicine Division of Endocrinology (Springfield, IL).