A Case of Malignant Hyperthermia in a Patient With Hyperosmolar Hyperglycemic State

Abstract

Malignant hyperthermia is a syndrome characterized by elevated temperature, heart rate, respiratory rate, and muscle rigidity, which eventually leads to a hypermetabolic state with rhabdomyolysis and increased oxygen consumption. It's typically seen in patients with genetic mutations predisposing them to a reaction after administration of anesthetics or depolarizing muscle relaxants, but there have been reported cases in response to other agents. Here we present a case of a patient who developed malignant hyperthermia after receiving insulin infusion for hyperosmolar hyperglycemic state. CASE PRESENTATION:A 24-year-old male with no significant past medical history who presented to the hospital for weakness and difficulty sleeping. In the ED the patient's blood glucose level was 1,635 on CMP with anion gap of 30. His lactic acid level was 3.5 before IV fluid resuscitation. In addition, admission ABG was found to have a pH 7.261, pCO2 33.8, and paO2 83.2 on room air. Vitals were BP 124/75, HR 130, RR 16, and Temp 97.5 F. Over the course of the next 12 hours, the patient's mental status started to decline. CT scan of the brain was performed, and was negative for acute intracranial pathology. He developed his first temperature of 102 F about 12 hours into his admission. The patient had already received 7L of normal saline and was receiving 1/2NS for maintenance fluids, which was then switched to D5W when the BG reached 250. After 20 hours of continued insulin drip for HHS and maintenance IV fluids his temperature increased to 103 F and he started to develop unstable tachyarrhythmias. He was cardioverted twice for supraventricular tachycardia which was unsuccessful. Further hemodynamic decline necessitated the patient to be intubated for airway protection and initiation of vasopressors. Subsequently he spiked a continued fever of 108 F which was not responsive to cooling blankets or tylenol. Patient was given two doses of dantrolene and his temperature was successfully lowered. Unfortunately the patient was already in multiorgan failure and DIC which resulted in cardiopulmonary arrest.DISCUSSION: There have been cases where a preservative cresol in insulin has caused individuals with susceptible genetics to malignant hyperthermia to develop the syndrome. Most known cases of malignant hyperthermia occur in individuals with ryanodine receptor (RYR1) or dihydropyridine receptor mutation (DHP) mutation. In a patient who did not receive the known triggers for malignant hyperthermia, the diagnosis was not on our differential until he had a persistent fever of 108 F. CONCLUSIONS:This case highlights a rare and potentially life threatening presentation of new onset diabetes mellitus. The mortality rate of malignant hyperthermia is 70-80% despite early recognition and treatment. We want to bring light to this potential complication to spread more awareness.