Hyperosmolar Hyperglycemic State With Reversible Encephalopathy in a Young Female on Chronic Steroids and Opioids: A Case Report

Hyperosmolar hyperglycemic state (HHS) is uncommon in young adults and may signal complex metabolic and pharmacologic interactions, particularly in the context of chronic glucocorticoid and opioid exposure. We describe a 22-year-old female with morbid obesity, idiopathic intracranial hypertension treated with ventriculoperitoneal shunting and neuromodulation, chronic high-dose steroid use, and opioid exposure who presented with severe hyperglycemia, dehydration, headache, and transient confusion. Laboratory findings revealed glucose level of 583 mg/dL, calculated osmolality of approximately 318 mOsm/kg, preserved C-peptide indicating severe insulin resistance, and suppressed adrenocorticotropic hormone and cortisol consistent with exogenous steroid-induced hypothalamic-pituitary-adrenal axis suppression. Urine ketones were present, but serum ketones were absent, supporting HHS without ketoacidosis. Neuroimaging excluded acute intracranial pathology. The patient improved with intravenous fluids, insulin therapy, treatment of intercurrent infection, and careful steroid tapering, achieving full neurologic recovery. This case highlights the potential for hyperosmolar neuro-metabolic crisis in young adults with chronic steroid and opioid exposure and emphasizes the importance of considering HHS in atypical populations, particularly when obesity, prolonged glucocorticoid therapy, and central nervous system depressants coexist.