Mixed Presentation of Hyperglycemic Hyperosmolar State and Diabetic Ketoacidosis in a Pediatric Patient: a Case Report and Literature Review

-ISPAD recommendations, she progressed to refractory shock and multiorgan failure, dying within 48 hours of admission. To the best of our knowledge, this represents one of the most extreme metabolic derangements reported in pediatric mixed hyperglycemic crisis. The convergence of extreme hyperosmolarity, concurrent sepsis, and structural comorbidities created a lethal risk phenotype in which sepsis, rather than the degree of metabolic derangement alone, appeared to determine the fatal outcome. Early recognition and an individualized therapeutic approach are essential to improve outcomes in vulnerable pediatric patients.