Rare Presentations of Ketoacidosis: Diabetic Ketoalkalosis and Ketoacidosis Secondary to Fasting and Muscular Dystrophy

D iabetic ketoacidosis (DKA), a hallmark of type 1 diabetes, is the result of uncontrolled production of ketone bodies (3-hy-droxybuturate and acetoacetic acid), leading to a lowering of blood pH (1). Ketogenesis in the liver is triggered by low levels of insulin and high levels of glucagon. In addition, other stress hormones (epinephrine, growth hormone, and cortisol), together with lack of insulin, accelerate lipolysis in peripheral tissues and lead to increased amounts of free fatty acids (FFAs) in the blood. FFAs are the most important precursor for ketone body formation. This process takes place in the mitochondiria (1). In general, ketoacidosis presents in patients with type 1 diabetes and is characterized by a high anion gap metabolic acidosis, which is usually compensated by hyperventilation and pulmonary loss of carbon dioxide. Below we report six unusual presentations of ketoacidosis. A 42-year-old man with known alcohol abuse and type 1 diabetes resulting from pancreatitis was brought to the hospital with vomiting, coughing, and general weakness. Before hospitalization , he had not taken any alkaline medicine or diuretics. His status at arrival and his blood test results are shown in Table 1. He had high 3-hydroxybutyrate (3-OHB), low potassium, and an anion gap >12 mEq/L. His condition was furthermore complicated by pneumonia. He was moved to the intensive care unit (ICU), where treatment with antibiotics , insulin, glucose, and potassium was initiated, and he recovered. A 28-year-old woman with type 1 diabetes was hospitalized. She had multiple complications, including nephropathy, retinopathy, peripheral neuropathy, gastroparesis treated with gastric electric stimulation (GES), and impaired urinary bladder function. On admission, she had symptoms of urinary tract infection (UTI) and reported having undergone eye surgery with local anesthesia the day before. She reported abdominal discomfort and vomiting. Blood test results (Table 1) showed hyperglycemia, high 3-OHB, pH of 7.47 indicating alkalosis, and low levels of bicarbon-ate compensated by hyperventilation. She was treated with insulin, glucose, and potassium and recovered fully. A 38-year-old woman with type 1 diabetes, nephropathy, incipient ret-inopathy, and gastroparesis treated with GES was hospitalized with lower stomach pain, signs of a UTI, and vomiting. She had a metabolic alkalo-sis and high 3-OHB (Table 1). Serum chloride was not measured. The infection and DKA were successfully treated with antibiotics, insulin, glucose, and potassium. A healthy 50-year-old man was brought to the hospital with nau-©2015 by the American Diabetes Association. Readers may use this article as …