Background Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are both hyperglycemic emergencies that are associated with a wide range of complications If not recognized and treated early and aggressively. Therefore, meticulous monitoring of clinical and biochemical responses to treatment is necessary so that timely adjustments to treatment can be made. Despite the fact that DKA is more common than HHS in type 1 DM, rates of treatment complications and mortality are substantially higher in HHS than those of DKA. An even higher risk of complication is associated with the overlap of both conditions. These complications include cerebral, renal, and thromboembolic manifestations.

Case Report(s) A 9-year-old girl presented with mixed DKA and HSS. Her condition was complicated by acute kidney injury (AKI), fungal sinusitis, cavernous sinus thrombosis, and panophthalmitis. ENT examination revealed: rt acute suppurative otitis media (ASOM) bulging tympanic membrane, rt lower motor neuron facial palsy lesion, endoscopic examination showed nose gangrene and necrotic tissue, and rt fronto-ethmoidal and rt maxillary sinusitis (clinical, radiological and histopathological features strongly suggest invasive fungal infection (rhinocerberal mucomycosis)). Ophthalmological examination showed corneal opacity and eye swelling (panophthalmitis). MRI, MRA, and MRV showed rt-sided cavernous thrombosis. The management was started according to the protocol adopted at our unit, which included a combination of sinus debridement, antibiotics, antifungals, and eye inoculation with prosthetic eye implantation.

Conclusion(s) This case highlights the importance of recognizing mixed DKA and HHS cases and the higher risk of complication and mortality in overlapping diseases.