A51-52 Something Doesn’t Add Up: HHS Complicated by Xylazine Withdrawal

Abstract Case 41yo male with PMHx of T2DM, chronic back pain controlled with opioids, and anxiety on alprazolam. He was brought to the ED after several days of nausea/vomiting. On exam, he appeared lethargic, minimally responsive to questioning. Labs revealed glucose 1197, serum Osm 350, beta-hydroxybutyrate 8.75, and an anion gap of 25. Initial concern was that he was in a mixed Diabetic Ketoacidosis (DKA)/Hyperosmolar Hyperglycemic State (HHS). He was begun on an insulin drip, fluid boluses, and admitted to the ICU. By the following morning, the patient had been adequately fluid resuscitated, and his anion gap had closed. On subsequent examination, the patient remained minimally responsive to questioning and became agitated. Family was contacted at this time who let us know that the patient may have been abusing his prescribed oxycodone, and alprazolam and maybe buying drugs off the street. He was loaded with phenobarbital for suspected benzodiazepine withdrawal. Despite this, the patient remained encephalopathic, now 24+ hours after DKA/HHS resolution. He was started on a dexmedetomine drip for suspected Xylazine withdrawal. Xylazine, an alpha-2 agonist, is a common street drug known as “tranq” to users. He was able to wean off dexmedetomidine after several days. When he became lucid again, he told staff that he was abusing heroin that he believed was laced with Xylazine. He was discharged from the hospital the following day. Discussion In HHS, patients often present with significantly altered mental status, even coma. The high serum glucose leads to a hyperosmolar state which pulls fluid intravascularly, effectively dehydrating brain tissue, leading to encephalopathy. While this is a well-known phenomenon in the disease course of HHS, if patients fail to improve cognitively with adequate treatment, it is important to look for an underlying cause of altered mental status, as this could be why a patient entered HHS in the first place. Xylazine is a potent alpha-2 agonist that is commonly mixed into street drugs. It is prevalent in the northeastern United States and poses many challenges to the medical system, as it is highly addictive with prolonged withdrawals. The current standard of care is supportive with alpha-2 agonists (dexmedetomidine, clonidine) as necessary to ameliorate symptoms. In this case, the patient admitted to neglecting his diabetes medications for a prolonged time, and once he began intractably vomiting secondary to entering DKA/HHS, he was no longer able to tolerate pills and stopped IV drugs, leading to withdrawal, an underlying encephalopathy. This abstract is funded by: None