Abstract
A case of hyperosmolar, non-ketotic, diabetic coma, complicated by metabolic acidosis, is reported.
The patient was a 62-year-old man, who had been diabetic for 28 years and recently had been treated with 20 units of insulin per day. Last year he was diagnosed as having dementia presenilis in addition to diabetic triopathy. Urinary tract infection and withdrawal of insulin, during hospitalization for psychiatric treatment were considered to be the factors causing the hyperosmolar, non-ketotic, diabetic coma. Physical examination on admission revealed a semicoma. Blood pressure was 68/40 mmHg, and respirations were 32 per minute. Kussmaul's respiration and acetone odor were absent. There was generalized areflexia. No pathological reflexes could be elicited. Laboratory studies revealed the following values; blood glucose, 3, 685 mg/dl; plasma osmolality, 466 mOsm/L; serum sodium, 131 mEq/L; serum potassium, 4.7 mEq/L; serum chloride, 92mEq/L; blood urea nitrogen, 130mg/dl; serum creatinine, 8.2 mg/dl; arterial blood, pH 7.12; bicarbonate, 9.6 mEq/L; blood lactate, 4.9 mEq/L; anion gap, 34.1 mEq/L. Results of urinalysis showed 1+proteinuria and 3+glycosuria, without acetonuria. In spite of treatment with 1, 124 units of insulin and 14, 500 ml of intravenous fluids, shock and anuria persisted, and generalized edema appeared on the second day of hospitalization. Hemodialysis for renal failure was performed in vain, and the patient's general physical state showed no changes. On the morning of the third day of hospitalization, he died of circulatory failure. Autopsy revealed diabetic glomerulosclerosis, mild fibrosis of pancreatic islets, and generalized arteriosclerosis.
In reviewing 204 cases of hyperosmolar, non-ketotic, diabetic coma reported in Japan, there were 29 cases complicated by metabolic acidosis (pH below 7.35). Mortality in the complicated cases was 46.6% in contrast to 40.6% in the other cases (P<0.05). Many cases were accompanied by various renal complications, and a few cases were considered to be of a type between diabetic ketoacidosis and hyperosmolar, non-ketotic, diabetic coma. However, no apparent cause of metabolic acidosis was revealed in the majority of the cases. In the present case, metabolic acidosis was suspected to be caused by uremia and lactic acidosis.
