Rapunzel syndrome is a very rare type of trichobezoar in which a hair mass extends to the stomach and small intestine forming a body and tail. It usually affects young females with a psychiatric background. Symptoms are usually nonspecific and often delay the diagnosis. We present in this report a case of a six-year-old previously healthy girl who presented with two months of intermittent abdominal pain, vomiting, and constipation. Initial laboratory tests and two times abdominal ultrasounds were unremarkable. Abdominal X-ray showed moderate dilatation of the bowel. Further physical examination revealed patchy scalp alopecia, raising suspicion for hair ingestion. Upper endoscopy showed a large trichobezoar in the stomach and duodenum, but endoscopic removal failed. The patient underwent open laparotomy, and an 11 × 4 cm bezoar with a tail extending into the duodenum was removed. This case highlights the value of recognizing Rapunzel syndrome in children with vague gastrointestinal symptoms, even without a prior psychiatric history. Early recognition and management, including surgical and non-surgical interventions, are important to prevent complications and recurrence. The study aims to describe a rare presentation of Rapunzel syndrome in order to increase awareness among physicians and emphasize the importance of early recognition and treatment to prevent serious complications.

Hirsutism is defined as a condition in which women develop excessive body hair in androgen-dependent areas, which include lips, chin, chest, abdomen, back, and femoral region. The link between hyperandrogenism and insulin resistance and/or hyperinsulinemia is well established. Polycystic ovary syndrome, as a form of hyperandrogenism, has been linked to several diseases, including type 2 diabetes mellitus and hirsutism. However, it is unknown how common hyperandrogenic problems are in women who receive exogenous insulin. Therefore, this study aims to assess the effect of insulin intake and other sociodemographic factors on the development of hirsutism among diabetic females. This case-control study was conducted in six regions of Saudi Arabia, including Al-Ahsa, Dammam, Qatif, Riyadh, Abha, and Jeddah, during the year 2022. The population was Saudi females who were diabetic, between the age of 18 and 65 years, and living in Saudi Arabia. The sample size was 186 participants. Of the participants, 48 had considerable hirsutism whereas 138 did not. The degree of hirsutism has been determined using the Ferriman and Gallwey scoring tool. A total of 186 diabetic females were included in the study. Among the females, 97 (52.2%) were on insulin therapy and 89 (47.8%) were on non-insulin therapies. Only hair distribution on the chin showed a significant difference between the study groups where 4.1% of cases on insulin showed complete cover with light or heavy hair on the chin compared to 3.4% of controls (P = 0.049). There was no significant difference regarding hirsutism score among the study patients according to insulin intake where the mean score was 5.4 ± 5.1 among cases on insulin versus 4.7 ± 5.1 for controls (P = 0.978). Adjusted logistic regression models showed an insignificant association between diabetic female hirsutism and insulin intake (OR = 1.1 and 1.0, respectively; P > 0.05). Many factors were examined to reveal their associations with hirsutism in diabetic females. Neither the type of diabetes nor insulin intake was significantly correlated with the development of hirsutism. On the other hand, age was found to be significantly associated with the development of hirsutism among age groups (<30, 30-49, and 50+; P = 0.49). It seemed that the prevalence of hirsutism decreases as age advances.

Hyperosmolar hyperglycemic state (HHS) is an uncommon but life-threatening hyperglycemic emergency in children and is more often associated with type 2 diabetes mellitus. We report a 13-year-old boy with a lean habitus and no previously diagnosed chronic illnesses who presented after three weeks of polyuria, polydipsia, fatigue, and weight loss. On admission, serum glucose was 1,080 mg/dL (60 mmol/L), hemoglobin A1c was 13.8%, measured serum osmolality was 331 mOsm/kg, calculated effective osmolality was 324 mOsm/kg, venous pH was 7.29, bicarbonate was 23.1 mmol/L, beta-hydroxybutyrate was 0.7 mmol/L, and urine ketones were negative. The biochemical profile met pediatric HHS criteria without significant ketoacidosis. He received an initial 20 mL/kg bolus of 0.9% sodium chloride followed by controlled deficit replacement. Intravenous insulin at 0.05 units/kg/hour was deliberately delayed until four hours after the initiation of fluid therapy, when the decline in glucose with fluids alone slowed to <50 mg/dL/hour. Glucose and effective osmolality then declined in a controlled fashion, while measured sodium rose gradually as hyperglycemia corrected; dextrose was added when glucose reached 275 mg/dL. No neurologic, thrombotic, renal, or major electrolyte complications occurred. Strongly positive GAD65 antibodies and a low C-peptide concentration obtained during concurrent hyperglycemia supported autoimmune type 1 diabetes mellitus (T1DM). The patient transitioned to subcutaneous basal-bolus insulin and was discharged on day 3. At three months, hemoglobin A1c was 7.0%. This case illustrates that HHS may be the first manifestation of autoimmune T1DM even in a lean adolescent and emphasizes the importance of interpreting glucose, sodium, and effective osmolality together while prioritizing controlled fluid replacement before insulin.

Background and Clinical Significance: Diabetic ketoacidosis (DKA) is a common presentation of new-onset type 1 diabetes mellitus in children; however, severe DKA complicated by acute pancreatitis, dialysis-requiring acute kidney injury (AKI), severe hypertension, and neurological involvement is uncommon. Early recognition of these complications is essential because they may substantially increase morbidity and complicate standard DKA management; Case Presentation: An 11-year-old Saudi girl with morbid obesity (BMI 43 kg/m²), previously in good health, was brought to the emergency department after being found semi-conscious. She had experienced intermittent abdominal pain for five weeks and vomiting for four days. On presentation, she was critically ill, dehydrated, and confused (Glasgow Coma Scale 11/15) and exhibited Kussmaul breathing and abdominal tenderness. Laboratory investigations confirmed severe new-onset DKA, with a blood glucose level of 684 mg/dL, pH < 7.0, HbA1c 12.2% and an anion gap > 37 mEq/L. Despite standard DKA management, metabolic acidosis persisted and renal function progressively deteriorated, accompanied by oliguria and severe hypertension reaching 200 mmHg. By day 4, the patient developed anuria and marked creatinine elevation to 560 µmol/L. Brain magnetic resonance imaging demonstrated cerebral microhemorrhages in the setting of multifactorial encephalopathy. Continuous kidney replacement therapy was initiated for KDIGO stage 3 AKI with refractory metabolic acidosis. Autoimmune testing supported the diagnosis of type 1 diabetes mellitus, while renal biopsy demonstrated acute tubular injury; Conclusions: This case highlights a rare, severe multisystem presentation of pediatric DKA. Close monitoring for renal, neurological, pancreatic, and hypertensive complications is crucial, particularly when the clinical course does not improve as expected with standard therapy.