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      Full recovery from extreme hypernatremia in an elderly woman with hyperosmolar hyperglycemic syndrome and abnormal electroencephalogram

      case-report

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          Abstract

          Background:

          Hyperosmolar hyperglycemic state is a life-threatening endocrine disorder that most commonly affects adults with type 2 diabetes mellitus. The condition results from an osmotic diuresis-induced loss of water exceeding that of sodium. Altered mental status, hypernatremia and hyperglycemia are characteristic features at presentation. Abnormal electroencephalogram findings have been reported. Successful therapy requires judicious fluid replacement and close monitoring.

          Case:

          A 78-year-old Hispanic female with a significant past medical history of type 2 diabetes mellitus was admitted with altered mental status, severe hypernatremia and hyperglycemia. She was diagnosed with hyperosmolar hyperglycemic state, and fluid therapy was started. A continuous electroencephalogram revealed left frontocentral and temporal periodic lateralized epileptiform discharges that resolved as her hypernatremia and dehydration were treated. She survived and was discharged after 1 week of treatment.

          Conclusion:

          Abnormal electroencephalogram findings consistent with nonconvulsive seizure activity may be temporary and reversible and do not suggest a poor prognosis in an elderly patient suffering from hyperosmolar hyperglycemic state and altered mental status.

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          Most cited references15

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          Association of Periodic and Rhythmic Electroencephalographic Patterns With Seizures in Critically Ill Patients.

          Periodic and rhythmic electroencephalographic patterns have been associated with risk of seizures in critically ill patients. However, specific features that confer higher seizure risk remain unclear.
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            Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state.

            Diabetic ketoacidosis and the hyperglycemic hyperosmolar state are the most serious complications of diabetic decompensation and remain associated with excess mortality. Insulin deficiency is the main underlying abnormality. Associated with elevated levels of counterregulatory hormones, insulin deficiency can trigger hepatic glucose production and reduced glucose uptake, resulting in hyperglycemia, and can also stimulate lipolysis and ketogenesis, resulting in ketoacidosis. Both hyperglycemia and hyperketonemia will induce osmotic diuresis, which leads to dehydration. Clinical diagnosis is based on the finding of dehydration along with high capillary glucose levels with or without ketones in the urine or plasma. The diagnosis is confirmed by the blood pH, serum bicarbonate level and serum osmolality. Treatment consists of adequate correction of the dehydration, hyperglycemia, ketoacidosis and electrolyte deficits.
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              Language guiding therapy: the case of dehydration versus volume depletion.

              Indiscriminate use of the terms dehydration and volume depletion, so carefully crafted by our predecessors, risks confusion and therapeutic errors. These two conditions should be distinguished at the bedside and in how we speak to one another. Dehydration largely refers to intracellular water deficits stemming from hypertonicity and a disturbance in water metabolism. The diagnosis of dehydration cannot be established without laboratory analysis of p[Na +] or calculation of serum tonicity. In contrast, volume depletion describes the net loss of total body sodium and a reduction in intravascular volume and is best termed extracellular fluid volume depletion. The diagnosis of this condition relies principally on history, careful physical examination, and adjunctive data from laboratory studies. The pathophysiology of both dehydration and extracellular fluid volume depletion must be understood if these conditions are to be recognized and appropriately treated when they occur separately or together. There is no inclusive therapy for all situations. For example, indiscriminate treatment with 0.45% saline cannot be recommended when these conditions coexist because extracellular fluid volume depletion is often treated rapidly with 0.9% saline and dehydration is often treated more slowly with 5% dextrose.
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                Author and article information

                Journal
                SAGE Open Med Case Rep
                SAGE Open Med Case Rep
                SCO
                spsco
                SAGE Open Medical Case Reports
                SAGE Publications (Sage UK: London, England )
                2050-313X
                14 May 2019
                2019
                : 7
                : 2050313X19848887
                Affiliations
                [1 ]Department of Internal Medicine, Orlando Regional Healthcare, Orlando, FL, USA
                [2 ]Division of Academic Affairs and Research, Orlando Regional Healthcare, Orlando, FL, USA
                Author notes
                [*]SJ Carlan, Division of Academic Affairs and Research, Orlando Regional Healthcare, 1401 Lucerne Terrace, 2nd floor, Orlando, FL 32806, USA. Email: stevecarlan@ 123456gmail.com
                Author information
                https://orcid.org/0000-0001-9867-8538
                Article
                10.1177_2050313X19848887
                10.1177/2050313X19848887
                6537048
                80ae761f-a646-4063-a579-7913590d28a5
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 27 November 2018
                : 16 April 2019
                Categories
                Case Report
                Custom metadata
                January-December 2019

                hyperosmolar hyperglycemic state,hypernatremia,continuous electroencephalogram,fluid resuscitation,dehydration

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