What is the appropriate management for a patient with hyperglycemia, leukocytosis, hypocalcemia, neutrophilia, and lymphopenia, suggesting potential diabetes and an acute infection, with normal kidney function?

Management of Hyperglycemia with Leukocytosis and Neutrophilia Suggesting Acute Infection

This patient requires immediate evaluation for hyperglycemic crisis (DKA or HHS) with urgent laboratory workup including arterial blood gases, serum ketones, electrolytes with anion gap calculation, and serum osmolality, followed by aggressive fluid resuscitation and insulin therapy if crisis is confirmed, while simultaneously initiating empiric broad-spectrum antibiotics for the suspected acute infection. 1, 2

Immediate Diagnostic Evaluation

The laboratory findings demand urgent assessment for hyperglycemic emergency:

• Blood glucose ≥250 mg/dL with symptoms requires immediate medical intervention to rule out DKA or HHS 1
• Essential immediate laboratory tests must include: arterial blood gases to assess pH, serum ketones (beta-hydroxybutyrate preferred), electrolytes with calculated anion gap, and effective serum osmolality 1, 2
• DKA diagnostic criteria: blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <18 mEq/L, positive serum ketones, and anion gap >10 mEq/L 2
• HHS diagnostic criteria: plasma glucose ≥600 mg/dL, arterial pH >7.30, serum bicarbonate ≥15 mEq/L, effective serum osmolality ≥320 mOsm/kg, small or absent ketones, and altered mental status or severe dehydration 1

The current anion gap of 5 is low, but this requires verification with proper calculation after obtaining complete metabolic panel 1.

Infection Assessment and Management

The marked leukocytosis (11.7 × 10³/μL) with severe neutrophilia (94.1%, absolute 11.10 × 10³/μL) and lymphopenia (3.2%, absolute 0.40 × 10³/μL) strongly indicates acute bacterial infection:

• Infection is the most common precipitating factor for both DKA and HHS 3, 4, 2
• The presence of fever, hyperglycemia, and leukocytosis in a diabetic patient strongly suggests infection as a precipitating factor for potential hyperglycemic crisis 2
• More total leukocytes and neutrophils are significantly correlated with DKA and can add valuable information to reflect the presence of hyperglycemic crisis and acute infection 5
• Systemic symptoms including marked leukocytosis or major metabolic disturbances denote a more severe, potentially limb-threatening or life-threatening infection 3

Specific Infection Considerations

Given the clinical context, evaluate for:

• Diabetic foot infection (DFI): Assess for any foot wounds, as DFIs are one of the most frequent diabetes-related complications requiring hospitalization 3
• Laboratory findings suggesting serious infection include plasma C-reactive protein or procalcitonin level >2 standard deviations above normal, uncontrolled hyperglycemia, and hyperlactaemia 3
• The procalcitonin of 0.04 is reassuringly low, suggesting bacterial infection may be less severe or localized 3
• Obtain vital signs, blood cultures, urinalysis with culture, and chest X-ray to identify infection source 3

Immediate Treatment Protocol

Fluid Resuscitation

• Aggressive fluid therapy must be initiated immediately with isotonic saline at 15-20 mL/kg/h during the first hour if DKA is confirmed 2
• Subsequent fluid choice depends on corrected serum sodium and hemodynamic status 2
• Hyperglycemia causes osmotic diuresis leading to hypovolemia, decreased glomerular filtration rate, and prerenal azotemia 3

Insulin Therapy

• Insulin therapy should be started after excluding hypokalemia (current potassium 4.3 is acceptable) 2
• If DKA confirmed: IV bolus of regular insulin 0.15 units/kg body weight, followed by continuous infusion at 0.1 units/kg/h 2
• Do not use metformin in this acute setting - it is contraindicated in patients with acute infection, dehydration, or risk of lactic acidosis 6

Antibiotic Therapy

• Initiate empiric broad-spectrum antibiotics immediately if severe infection is suspected, covering gram-negative organisms (E. coli, Klebsiella, Proteus) which are most common in diabetic infections 4
• Do not delay antibiotic administration while awaiting culture results in severe infection 3

Monitoring Requirements

• Blood must be drawn every 2-4 hours for serum electrolytes, glucose, blood urea nitrogen, creatinine, and serum osmolality 2
• Monitor for hypoglycemia - any blood glucose <70 mg/dL requires immediate treatment and review of insulin regimen 3
• The low calcium (8.3) requires monitoring and replacement as needed during treatment 3

Pathophysiological Context

• Hyperglycemia impairs leukocyte function, including decreased phagocytosis, impaired bacterial killing, and chemotaxis, leading to hospital infections and poor wound healing 3
• Diabetes causes immune dysfunction with aberrations in phagocytic cells, altered cytokine profiles, and impaired neutrophil migration 7, 8
• The combination of hyperglycemia and infection creates a vicious cycle where each worsens the other 3, 8

Transition to Subcutaneous Insulin

• Transition to subcutaneous insulin when DKA resolution criteria are met: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH >7.3 2
• Administer subcutaneous basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent crisis 2

Critical Pitfalls to Avoid

• Do not assume simple hyperglycemia without ruling out DKA/HHS - the consequences of missing hyperglycemic crisis are severe 1
• Do not delay antibiotics in suspected severe infection - diabetes-associated immune suppression increases infection severity 7, 8
• Do not use oral hypoglycemics (including metformin) during acute illness with infection and dehydration 6
• Do not correct osmolality too rapidly - change should not exceed 3-8 mOsm/kg/hour to prevent cerebral edema 4