Cocaine-Induced Mixed Diabetic Ketoacidosis-Hyperosmolar Hyperglycemic State Mimicking Acute Cholecystitis: A Case Report.

We present the case of a 52-year-old man with a history of diabetes mellitus who presented with altered mental status following acute cocaine use. Initial evaluation revealed severe hyperglycemia (1655 mg/dL), profound metabolic acidosis, hyperkalemia, and severe hypernatremia consistent with mixed diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The patient required endotracheal intubation, mechanical ventilation, continuous insulin infusion, aggressive fluid resuscitation, and electrolyte correction. His intensive care unit course was complicated by distributive shock requiring norepinephrine, phenylephrine, and vasopressin support. He subsequently developed transient cardiomyopathy with a left ventricular ejection fraction of 35% and marked transaminitis. Right upper quadrant ultrasonography and computed tomography demonstrated gallbladder sludge and borderline wall thickening, raising concern for acute cholecystitis. However, hepatobiliary scintigraphy was negative for cystic duct obstruction, and liver enzymes improved rapidly following hemodynamic stabilization. These findings supported a diagnosis of ischemic hepatitis secondary to shock and cocaine-induced vasoconstriction rather than primary biliary pathology. The patient's clinical status improved with supportive management, and he was discharged with outpatient endocrinology and cardiology follow-up. This case highlights the potential for cocaine-associated mixed DKA-HHS to present with profound metabolic derangement and multisystem organ dysfunction while mimicking acute biliary disease, emphasizing the importance of careful diagnostic evaluation to avoid unnecessary surgical intervention.