Hyperosmolar hyperglycemic state differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Overview

The hyperosmolar hyperglycemic state must be differentiated from other conditions presenting with hyperglycemia, hyperosmolarity or an altered state of consciousness. The differentials include diabetes mellitus, diabetic ketoacidosis, impaired glucose tolerance, and conditions causing altered sensorium such as CNS infections or stroke. All these conditions may be differentiated on the basis of history findings, clinical features, and laboratory abnormalities.

Differentiating Hyperosmolar Hyperglycemic State From Other Diseases

• Hyperosmolar hyperglycemic state must be differentiated from other diseases that present with hyperglycemia, hyperosmolarity, and altered state of consciousness.
• Hyperosmolar hyperglycemic state should also be differentiated from conditions that can cause focal neurological signs or an altered state of consciousness such as CNS infections and stroke by doing a simple finger stick glucose testing.

Diseases	Laboratory Findings	Physical Examination	History and Symptoms	Other Findings
Diabetes mellitus	Hyperglycemia: Fasting blood glucose level: >126 mg/dl Random blood glucose level: >200 mg/dl HbA1C: >6.5 % Urinanalysis may show: Proteinuria Glucosuria Positive antibodies: (Type 1 diabetes) Anti-glutamic acid decarboxylase Anti-islet cell Anti-insulin	Autonomic and peripheral neuropathy Decreased visual acuity (diabetic retinopathy) Central obesity(BMI >25 kg/m2) Hypertension (Blood pressure >140/90 mmHg)	Family history of diabetes Sedentary lifestyle Stress Polyuria Polydipsia Polyphagia Weight loss	History of gestational diabetes Polycystic ovarian syndrome Acanthosis nigricans
Diabetic ketoacidosis	Blood pH < 7.3 Serum bicarbonate < 18 mEq/L Anion gap > 10 mEq/L Increased serum osmolarity	May have all clinical features of diabetes mellitus Hypotension Tachycardia Dehydration	Younger age with type 1 diabetes mellitus Prolonged hyperglycemia Undiagnosed type 1 diabetes mellitus
Impaired glucose tolerance	Hyperglycemia: Fasting blood glucose level: 100-125 mg/dl Oral glucose tolerance test: 140-200 mg/dl	May have all clinical features of diabetes mellitus Obesity (BMI >25 kg/m2)	Family history of diabetes Sedentary lifestyle

Differentiating hyperosmolar hyperglycemic state from diabetic ketoacidosis (DKA) based on laboratory findings.

Parameters	Diabetic ketoacidosis (DKA)	Hyperosmolar hyperglycemic state (HHS)
Plasma glucose	> 250 mg/dl	> 600 mg/dl
Serum osmolality	Variable	> 320 mOsm/kg
Plasma and urine ketones	Positive	None or trace
Serum bicarbonate	< 18 mEq/L	> 15 mEq/ L
Arterial ph	< 7.30	> 7.30
Anion gap	> 12	< 12

References

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