Clinical Presentation

Diabetic Ketoacidosis (DKA)

• Signs and Symptoms:
  • Polyuria: Increased frequency of urination is often one of the first signs, driven by osmotic diuresis due to high blood glucose levels.
  • Polydipsia: Excessive thirst is typically a compensatory response to fluid loss from polyuria.
  • Polyphagia: Increased hunger can occur, although it may not be as evident due to nausea or vomiting.
  • Nausea, Vomiting, and Abdominal Pain: These symptoms are particularly common and can be severe, sometimes mimicking an acute abdomen. They are often associated with the degree of ketosis and acidosis.
  • Kussmaul Respiration: Deep and labored breathing pattern, often a compensatory mechanism for metabolic acidosis.
  • Acetone Breath: A fruity odor to the breath due to the presence of acetone, a type of ketone.
  • Altered Mental Status: Ranges from confusion to stupor and, in severe cases, coma. The severity of altered mental status is often proportional to the degree of acidosis and hyperosmolality.
• Demographics:
  • Typically more common in younger individuals, particularly those with Type 1 diabetes.
  • However, it can occur in adults and those with Type 2 diabetes, especially in the context of stress or illness.

Hyperosmolar Hyperglycemic Syndrome (HHS)

• Signs and Symptoms:
  • Extreme Dehydration: Dry, parched skin, sunken eyes, and other signs of volume depletion.
  • Altered Mental Status: Ranges from confusion to coma; severity often correlates with the degree of hyperosmolality.
  • Seizures or Focal Neurological Deficits: These may be present, especially when effective serum osmolality exceeds 320 mOsm/kg.
  • Absence of Kussmaul Respiration and Ketone Odor: Unlike DKA, HHS usually lacks these signs.
• Demographics:
  • More prevalent in older adults and those with Type 2 diabetes.
  • Often associated with a precipitating event like infection or medication nonadherence.

Common Pitfalls and Challenges in Diagnosis

• Euglycemic DKA: Often seen in patients on SGLT-2 inhibitors, it may not present with the classic symptoms of hyperglycemia, making diagnosis challenging.
• Abdominal Pain in DKA: Sometimes the abdominal pain can be so severe that it mimics conditions like appendicitis, leading to surgical consultations and potential misdiagnosis.
• Insidious Onset of HHS: Unlike DKA, which tends to have an acute onset, HHS can develop over days to weeks. This slow progression can make early detection and intervention challenging.

Summary Table