Beyond the Limits: Severe Hyperglycemia in Hyperosmolar Hyperglycemic State (Serum Glucose 2375 mg/dL)

Hyperosmolar hyperglycemic state (HHS) is a life-threatening diabetic emergency characterized by extreme hyperglycemia, dehydration, and absence of significant ketoacidosis. This case is noteworthy due to the patient's extraordinarily high serum glucose level of 2375 mg/dL, one of the highest recorded in literature. This report's objective is to describe a patient with HHS and profound hyperglycemia that challenges the known boundaries of human physiology.

A 28-year-old transgender man (assigned female at birth) receiving testosterone replacement therapy presented to a critical access hospital emergency department with severe nausea, vomiting, and signs of dehydration. He had insulin-dependent type I diabetes mellitus and stage 3 chronic kidney disease. Initial laboratory testing revealed serum glucose of 2375 mg/dL (reference range: 70-140 mg/dL). Laboratory analysis showed no ketoacidosis. He was diagnosed with a hyperosmolar hyperglycemic state. The patient was transferred to our hospital and treated with intravenous fluids and insulin. Laboratory values were closely monitored. Over several days, glucose levels declined to reference ranges. His symptoms resolved, and he was discharged in a stable condition.

HHS typically occurs in older adults with type 2 diabetes and is associated with infections or organ failure. Serum glucose above 2000 mg/dL is rarely reported. This case stands out due to the significant level of hyperglycemia.

This case contributes to limited literature on profound hyperglycemia and emphasizes the importance of early recognition and treatment.