Acute onset sleep apnea with severe transient hyperglycemia in young adult: the diagnostic dilemma and management controversy

Brajesh Mishra, Bhawesh Mishra


Sleep disordered breathing and obstructive sleep apnea are frequently associated with hyperglycemic disorders. The common pathophysiological factors that link these disorders have been a matter of debate and current research. Abdominal adiposity and high body mass index are considered to predispose individuals to early onset of type 2 diabetes and related metabolic disorders. A young adult presenting with symptoms of obstructive sleep apnea often poses a diagnostic challenge for clinicians especially when multiple risk factors coexist. It is essential to establish the exact diagnosis so that specific treatment can be initiated. The role of a non-aggressive approach in management of severe hyperglycemic conditions has been doubted. We report a case of a 33 year old man presenting to the respiratory outdoor clinic for recent onset loud snoring and increased daytime sleepiness. Routine biochemistry reports revealed hyperlipidemia and severe hyperglycemia. The patient was ambulatory and stable throughout. The subsequent investigations identified multiple stressors and the possibility of a single cause was analysed. A rapid glycemic control and amelioration of symptoms were observed based on consistent monitoring and a conservative clinical approach. The key findings and relevant review of literature are discussed in this article.


Sleep disordered breathing, Obstructive sleep apnea, Metabolic syndrome, Syndrome Z, Snoring, Severe hyperglycemia

Full Text:



Tasali E, Mokhlesi B, Cauter EV. Obstructive sleep apnea and type 2 diabetes interacting epidemics. Chest 2008;133:496-506.

Shaw JE, Punjabi NM, Wilding JP, Alberti KGMM, Zimmet PZ. Sleep-disordered breathing and type 2 diabetes. Diabetes Research and Clinical Practice 2008;81:2-12.

Wilcox I, McNamara SG, Collins FL, Grunstein RR, Sullivan CE. “Syndrome Z”: The interaction of sleep apnoea, vascular risk factors and heart disease. Thorax 1998;53 Suppl 3:S25-28.

Ravindran C, Arun P, Hari LP. Syndrome Z- The new metabolic syndrome. Calicut Medical Journal 2007;5(1)e1:1-3.

Tasali E, Ip MS. Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation. Proc Am Thorac Soc 2008;5:207-17.

Priou P, Le Vaillant M, Meslier N, Chollet S, Masson P, Humeau MP, Pigeanne T, Bizieux-Thaminy A, Goupil F, Gagnadoux F. IRSR Sleep Cohort Group. Independent association between obstructive sleep apnea severity and glycated hemoglobin in adults without diabetes. Diabetes Care 2012;35:1902-6.

Sharma SK, Ahluwalia G. Epidemiology of adult obstructive sleep apnoea syndrome in India. Indian J Med Res 2010;131:171-5.

Veasey SC, Guilleminault C, Strohl KP, Sanders MH, Ballard RD, Magalang UJ. Medical therapy for obstructive sleep apnea. SLEEP 2006;29:1036-44.

Owen KR, Stride A, Ellard S, Hattersley AT. Etiological investigation of diabetes in young adults presenting with apparent type 2 diabetes. Diabetes Care 2003;26:2088-93.

Nguyen QM, Xu JH, Chen W, Srinivasan SR, Berenson GS. Correlates of age onset of type 2 diabetes among relatively young black and white adults in a community: The Bogalusa Heart Study. Diabetes Care 2012;35:1341-6.

Vgontzas AN, Bixler EO, Chrousos GP. Sleep apnea is a manifestation of the metabolic syndrome. Sleep Medicine Reviews 2005;9:211-24.

Roberts CK, Barnard RJ. Effects of exercise and diet on chronic disease. J Appl Physiol 2005;98:3-30.

Parekh R, Green E, Majeed A. Obstructive sleep apnoea: quantifying its association with obesity and snoring. Prim Care Respir J 2012;21:361-70.

Stradling JR, Crosby JH. Predictors and prevalence of obstructive sleep apnoea and snoring in 1001 middle aged men. Thorax 1991;46:85-90.

Counter P, Wilson JA. The management of simple snoring. Sleep Medicine Reviews 2004;8:433-41.

Alberti KG, Zimmet P, Shaw J. Metabolic syndrome- a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006;23:469-80.

Meyer S, Eddleston M, Bailey B, Desel H, Gottschling S, Gortner L. Unintentional Household Poisoning. Klin Padiatr 2007;219:254-70.

Surwit RS, Schneider MS, Feinglos MN. Stress and diabetes mellitus. Diabetes Care 1992;15:1413-22.

Mitra A. Diabetes and Stress: A Review. Ethno-Med 2008;2:131-5.

Flint RW, Jr. Emotional Arousal, Blood Glucose Levels, and Memory Modulation: Three Laboratory Exercises in Cognitive Neuroscience. The Journal of Undergraduate Neuroscience Education 2004;3:A16-A23.

Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet 2009;373:1798-807.

Pozzilli P, Mario UD. Autoimmune Diabetes Not Requiring Insulin at Diagnosis (Latent Autoimmune Diabetes of the Adult). Diabetes Care 2001;24:1460-7.

Naik RG, Barbara M, Worrell B, Palmer JP. Latent Autoimmune Diabetes in Adults. J Clin Endocrinol Metab 2009;94:4635-44.

Haffner SM. The Metabolic Syndrome: Inflammation, Diabetes Mellitus, and Cardiovascular Disease. Am J Cardiol 2006;97[suppl]:3A-11A.

Lui MM, Lam JC, Mak HK, Xu A, Ooi C, Lam DC, Mak JC, Khong PL, Ip MS. C-Reactive Protein Is Associated With Obstructive Sleep Apnea Independent of Visceral Obesity. Chest 2009;135:950-6.

Pakhetra R, Garg MK, Suryanarayana KM. Management of Hyperglycemia in Critical Illness: Review of Targets and Strategies. MJAFI 2011;67:53-7.

Inzucchi SE. Management of Hyperglycemia in the Hospital Setting. N Engl J Med 2006;355:1903-11.

Pillar G, Shehadeh N. Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care 2008;31 Suppl 2:S303-9.

Athanassiou IK, Athanassiou P. Metabolic syndrome and sleep apnea. Hippokratia 2008;12:81-6.

Bonsignore MR, Eckel J. Metabolic aspects of obstructive sleep apnoea syndrome. Eur Respir Rev 2009;18:112, 113-24.

Tahara Y, Shima K. The response of glycated hemoglobin to stepwise plasma glucose change over time in diabetic patients. Diabetes Care 1993;16:1313-4.

Executive Summary: Standards of medical care in diabetes-2009. Diabetes Care 2009;32:S6-S12.

Wing RR, Lang W, Wadden TA, Safford M, Knowler WC, Bertoni AG, et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care 2011;34:1481-6.