This report describes a case of a 50-year-old male who presented with complaints of hyposthenia, anorexia, and dizziness for four days. He described a history of type 2 diabetes mellitus for ten years (well controlled with HbA1C at 6.1~6.3%) and had been taking metformin but stopped taking it for three months and was consuming dapagliflozin only. He began experiencing weight loss, frequent hunger, and increased appetite in the last two months. Additionally, he reported frequent consumption of sodas, coffee drinks high in calories, and fruit juice.

He also documented high blood pressure and hyperlipidemia; and was taking amlodipine, olmesartan, pitavastatin, fenofibrate, and aspirin.

Physical examination revealed weight, blood pressure, pulse, respiration, and body temperature as 104.5 kg, 120/70 mmHg, 88 breaths/min, 20 beats/min, and 37.4℃, respectively. He displayed an acute ill-looking appearance, low skin tension, and severely dried oral mucosa, accompanied by dehydration. 

His breathing sound and bowel sound were good, and his abdominal examination was normal.

Lab investigations revealed hemoglobin, white blood cells, and platelet count as 15.3 g/dL, 12,210/mm3 (segmented neutrophil: 95%, lymphocyte:3%), and 264,000/mm3, respectively. Blood glucose, HbA1C, blood urea nitrogen, and creatinine as 2,050 mg/dL, 10.5%, 46.1 mg/dL, and 3.4 mg/dL, respectively. Sodium, potassium, chlorine, calcium, phosphorus, carbon dioxide, C-reactive protein, serum osmotic pressure, and fasting C-peptide levels as 120.3 mEq/L, 6.2 mEq/L, 86 mEq/L, 10.1 mg/dL, 4.6 mg/dL, 28.3 mmol/L, 0.2 mg/dL, 412 mOsm/kg, and 5.6 ng/mL, respectively. His urine ketone level was negative, and his urinary osmotic pressure was 542 mOsm/kg. Blood tests and urine tests showed normal ranges. Chest and abdominal X-rays were also normal. An electrocardiogram showed left ventricular hypertrophy, and abdominal ultrasonography showed mild fatty liver. 

He received a diagnosis of acute renal failure accompanying hyperosmolar hyperglycemic syndrome and started to receive fluid and insulin treatment. On the second day of hospitalization, his blood sugar level remained between 200~400 mg/dL. His Hyposthenia, anorexia, and dizziness improved and showed no evidence of fever or infection. On the third day, his creatinine level recovered to 1.1 mg/dL, and his blood sugar was well maintained. Thus, on the fourth day, treatment was switched to subcutaneous insulin infusion and multiple doses of insulin regimen. The patient then received a discharge. After that, he received ambulatory care and combined administration of 30 units of Detemir, 1000mg/day of metformin, and 100mg/day of vildaglpitin. His HbA1C in two months and five months after discharge were 8.2 % and 5.2%, respectively. Therefore, insulin administration was stopped, and he was prescribed 1000mg/day of metformin and 100 mg/day of sitagliptin only.

Nho I-Y, Kim H-S, Kang N-K, Lee M-W, Kim S-K, Park S-O. Case of hyperosmolar hyperglycemic state by sodium-glucose cotransporter 2 inhibitors. Kosin Medical Journal 2018; 33(3): 402-408.DOI: https://doi.org/10.7180/kmj.2018.33.3.402