What is the best course of action for a 32-year-old female patient with hyperglycemia (elevated blood sugar), leukocytosis (increased white blood cell count), eosinophilia (increased eosinophils), and thrombocytosis (increased platelet count), who presented with dizziness and headaches, but currently has no symptoms?

Immediate Management of Severe Hyperglycemia with Hematologic Abnormalities

This patient requires urgent initiation of insulin therapy combined with metformin to rapidly correct the severe hyperglycemia (random blood glucose 19.24 mmol/L or 346 mg/dL), while simultaneously investigating the underlying cause of the leukocytosis and eosinophilia. 1

Critical Initial Assessment

Rule out hyperglycemic crisis immediately by checking for:

• Ketones (urine or serum) and metabolic acidosis to exclude diabetic ketoacidosis (DKA), as patients with blood glucose >250 mg/dL without known diabetes may present with DKA 2, 3
• Symptoms of hyperglycemia (polyuria, polydipsia, weight loss) that may have been missed 2
• Serum osmolality if blood glucose approaches or exceeds 600 mg/dL to assess for hyperosmolar hyperglycemic state (HHS) 2, 3
• Electrolytes with calculated anion gap, renal function, and complete metabolic panel 2, 3

Confirm diabetes diagnosis with repeat testing:

• The random blood glucose of 19.24 mmol/L (346 mg/dL) meets criteria for "diabetic type" 4, 5
• Obtain HbA1c immediately to assess chronic glycemic control and confirm diagnosis 2
• If HbA1c ≥6.5% along with this elevated random glucose, diabetes is confirmed without need for repeat testing 2
• If HbA1c <6.5%, repeat fasting plasma glucose or 2-hour oral glucose tolerance test on a separate day to confirm diagnosis 2

Insulin and Metformin Initiation

Start dual therapy immediately given the severity of hyperglycemia:

Basal Insulin Regimen

• Initiate basal insulin (glargine/Lantus) at 0.5 units/kg/day administered once daily at bedtime 1
• For a 70 kg patient, start with approximately 35 units daily 1
• Titrate every 2-3 days based on fasting blood glucose, targeting 80-130 mg/dL (4.4-7.2 mmol/L) 1

Prandial Insulin Coverage

• Add rapid-acting insulin (lispro/Humalog) before each main meal using a basal-bolus regimen 1
• Start with 4-6 units before each meal, or calculate as 50% of total daily insulin dose divided among three meals 1

Metformin Therapy

• Start metformin 500 mg twice daily with meals if renal function is normal (eGFR >30 mL/min) 1, 6
• Titrate up to 1000 mg twice daily over 1-2 weeks to minimize gastrointestinal side effects 1
• Continue metformin long-term even after insulin is initiated 1

Investigation of Hematologic Abnormalities

The combination of leukocytosis, eosinophilia, and thrombocytosis requires systematic evaluation:

Eosinophilia Workup

• Obtain detailed travel history, medication review, and assess for allergic conditions or parasitic infections 7
• Consider stool examination for ova and parasites if travel history or symptoms suggest parasitic infection 7
• Review for new medications that could cause drug-induced eosinophilia 7

Leukocytosis Evaluation

• Infection is the most common cause of leukocytosis and should be actively sought, particularly given the recent symptoms of dizziness and headaches 7
• Stress-related leukocytosis from acute hyperglycemia itself can cause white blood cell count to double within hours 7
• Obtain peripheral blood smear to assess white blood cell morphology, maturity, and presence of toxic granulations 7
• Consider inflammatory conditions, smoking history, obesity, and medication effects as nonmalignant causes 7

Thrombocytosis Assessment

• Reactive thrombocytosis is common with infection, inflammation, or iron deficiency 7
• If platelet count is markedly elevated (>600,000/μL) or other concerning features present, consider hematology referral 7

Monitoring Protocol

Intensive glucose monitoring is essential:

• Check fasting glucose daily and pre-meal/2-hour post-meal glucose at least 3-4 times daily initially 1
• Measure HbA1c every 3 months to assess glycemic control 1, 2
• Target HbA1c <7.0% (53 mmol/mol) for most patients, with more stringent targets of <6.5% if achieved without significant hypoglycemia 1, 2

Monitor for hypoglycemia:

• Educate patient on recognition and treatment of hypoglycemia, as insulin therapy carries this risk 6
• Provide glucose tablets and emergency glucagon if appropriate 6

Expected Outcomes and Follow-up

With aggressive basal-bolus insulin plus metformin:

• Expect HbA1c reduction of approximately 3-4% over 3-6 months 1
• Most adherent patients should achieve HbA1c <7% within 6 months 1
• Once glycemic targets are consistently achieved, insulin can be reduced by 10-30% every few days while continuing metformin 1, 2

Repeat complete blood count in 2-4 weeks:

• If hematologic abnormalities persist or worsen, refer to hematology for further evaluation 7
• If abnormalities resolve with treatment of hyperglycemia and any identified infection, continue routine monitoring 7

Critical Pitfalls to Avoid

• Never delay insulin therapy in patients with blood glucose approaching 300-350 mg/dL, as prolonged hyperglycemia increases complication risk 8
• Do not start insulin if potassium <3.3 mEq/L without first correcting hypokalemia, as this causes life-threatening cardiac complications 2, 3
• Do not assume asymptomatic means uncontrolled diabetes is benign—even without symptoms, patients are at increased risk for macrovascular and microvascular complications 2
• Do not attribute all findings to diabetes alone—the hematologic abnormalities require independent investigation as they may indicate concurrent infection or other pathology 7