title: Childhood diabetes presenting with hyperosmolar dehydration but without ketoacidosis: a report of three cases.
abstract: BACKGROUND
  Diabetic ketoacidosis (DKA) is a common mode of presentation of diabetes mellitus in children, accounting for 26% of new cases. Rarely, children with diabetes may develop other forms of metabolic decompensation associated with hyperglycaemia and hyperosmolality. Hyperglycaemia and hyperosmolality without ketoacidosis has high mortality in adults, although there is no data on mortality in children.
  
  
  METHODS
  We describe three children who presented to Birmingham Children's Hospital and were initially suspected to have DKA. Each child was severely hyperglycaemic and hyperosmolar but without significant ketosis or acidosis. In two of the three children, the hyperosmolar state was associated with the ingestion of large volumes of high calorie fluids preceding the presentation. These children were exquisitely sensitive to insulin and may be at a significantly higher risk of cerebral oedema in view of their hyperosmolar state.
  
  
  CONCLUSIONS
  Hyperosmolar hyperglycaemia is a serious and rare complication at presentation of diabetes in children, and should be distinguished from DKA. These children are at an increased risk of cerebral oedema compared with DKA, and one should have a low threshold for suspicion of this complication.
authors.affiliation: Birmingham Children's Hospital, Endocrinology and Diabetes, Birmingham, UK. melanie@packwood-cottages.freeserve.co.uk
authors.forename: M J R
authors.initials: MJ
authors.lastname: Kershaw
authors.forename: T
authors.initials: T
authors.lastname: Newton
authors.forename: T G
authors.initials: TG
authors.lastname: Barrett
authors.forename: K
authors.initials: K
authors.lastname: Berry
authors.forename: J
authors.initials: J
authors.lastname: Kirk
mesh_terms: D000293:Adolescent; D001929:Brain Edema / Q000517:prevention & control; D003922:Diabetes Mellitus, Type 1 / Q000150:complications*; D016883:Diabetic Ketoacidosis / Q000175:diagnosis; D005260:Female; D006801:Humans; D006944:Hyperglycemic Hyperosmolar Nonketotic Coma / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D008297:Male; D016896:Treatment Outcome