Presentation
A 47-year-old female with a history of insulin-dependent diabetes mellitus presented to the emergency department with vomiting, blurred vision, and severe abdominal pain. Her husband noted that she had become increasingly lethargic and confused over the past 24 hours. Upon arrival, she was found to have severe metabolic acidosis and was initially diagnosed with Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS). Despite the resolution of these conditions, she remained agitated and confused and was only able to answer simple questions with her name and the hospital's name.
Vital Signs
Blood Pressure: 100/38 mmHg (labile)
Heart Rate: 90 bpm
Respiratory Rate: 18 breaths per minute
Temperature: Hypothermic on arrival, currently normothermic
Oxygen Saturation: 95% on 10 liters of oxygen
Initial Laboratory Results
pH: 6.5 (severe acidosis)
PCO2: 14 mmHg (respiratory compensation)
Bicarbonate: <6 mmol/L
Lactic Acid: 22 mmol/L (elevated)
Beta-hydroxybutyrate (BHB): Elevated
Glucose: 360 mg/dL
Serum Osmolality (Calculated): 340 mOsm/kg
Serum Osmolality (Measured): 380 mOsm/kg
Ethanol: 240 mg/dL
Acetone: 74.2 mg/dL (elevated)
Creatinine: 1.29 mg/dL (mild acute kidney injury)
What is the most likely cause of this woman's symptoms and laboratory findings?
A) Methanol poisoning
B) Diabetic Ketoacidosis (DKA)
C) Alcoholic Ketoacidosis (AKA)
D) Ethylene glycol poisoning
E) Septic shock
F) Lactic acidosis from tissue hypoxia
G) Diabetic Ketoacidosis (DKA) and Alcoholic Ketoacidosis (AKA).
Reveal the answer
Diagnostic Considerations
The combination of severe metabolic acidosis, visual disturbances in acidosis, and altered mental status raised concerns about methanol poisoning. However, the elevated ethanol level suggested otherwise, as ethanol inhibits the metabolism of methanol, preventing its toxic effects. Additional diagnostic considerations included Diabetic Ketoacidosis (DKA), Alcoholic Ketoacidosis (AKA), and other causes of lactic acidosis such as septic shock or tissue hypoxia.
Differential Diagnosis
A) Methanol poisoning
B) Diabetic Ketoacidosis (DKA)
C) Alcoholic Ketoacidosis (AKA)
D) Ethylene glycol poisoning
E) Septic shock
F) Lactic acidosis from tissue hypoxia
G) Diabetic Ketoacidosis (DKA) and Alcoholic Ketoacidosis (AKA)
Diagnostic Journey
Methanol Poisoning: Initially considered due to the blurred vision and severe acidosis, but ruled out due to the high ethanol level, which inhibits methanol metabolism, and the absence of a significant osmolar gap.
Diabetic Ketoacidosis (DKA) and Alcoholic Ketoacidosis (AKA): Supported by the elevated beta-hydroxybutyrate (BHB), high glucose, and acetone levels, along with the patient's history of diabetes and possible recent alcohol use.
Lactic Acidosis from Tissue Hypoxia: Considered due to the elevated lactate levels, the resolution of lactic acidosis after treatment indicated that it was secondary to the ketoacidosis rather than a primary issue like sepsis or shock.
Final Diagnosis
The patient was diagnosed with Diabetic Ketoacidosis (DKA) and Alcoholic Ketoacidosis (AKA). The severe metabolic acidosis and visual symptoms were attributed to these combined metabolic disturbances rather than methanol poisoning.
Treatment and Outcome
The patient received treatment for DKA with insulin, intravenous fluids, and electrolyte management. Thiamine for alcohol-related conditions was administered to prevent Wernicke's encephalopathy due to her history of alcohol use. Her condition improved as the underlying ketoacidosis was corrected, with gradual stabilization of her acidosis and mental status.
Summary
This case emphasizes the need for a comprehensive approach when evaluating severe metabolic acidosis and altered mental status. While methanol poisoning differential diagnosis was crucial, the combination of DKA and AKA was ultimately correct, as confirmed by laboratory findings and clinical history. Clinicians should consider all possible contributing factors in complex metabolic emergencies to ensure accurate diagnosis and effective treatment.
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Authors:
Bio:
Dr. Omid Mehrpour is a distinguished medical toxicologist known for his extensive clinical and research expertise. He focuses on understanding and treating toxic exposures. Renowned for his ability to diagnose and manage poisoning cases, Dr. Mehrpour has authored numerous impactful publications and is dedicated to educating future medical toxicologists. His innovative approach and commitment to patient care make him a leading figure in medical toxicology.
References:
Garg, S., & Garg, P. (2021). Differential Diagnosis of Ketoacidosis in Hyperglycemic Alcoholic Diabetic Patient: Role of Insulin. Indian Journal of Critical Care Medicine, 25(10), 1203–1204. PubMed
Liu, J., Li, X., Wu, J., Chen, Y., Li, H., & Tian, Z. (2021). Non-diabetic ketoacidosis: A case of alcoholic ketoacidosis accompanied by hyperglycemia. The American Journal of Emergency Medicine. PubMed
Mousavi, S., Dadpour, B., Moshiri, M., Moghiman, T., Khosrojerdi, H., & Najari, F. (2019). Methanol Poisoning as a Trigger for the Presentation of Diabetes Mellitus: A Case Report. International Journal of Medical Toxicology and Forensic Medicine. PubMed
Gosmanov, A., Gosmanova, E. O., & Kitabchi, A. E. (2015). Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS). In Endotext [Internet]. PubMed
Lavrynenko, O., Santos, H., Garza, A., & Qazi, R. (2021). Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor. Clinical Diabetes Research. PubMed
Hockenhull, J., Dhillo, W., Andrews, R., & Paterson, S. (2012). Investigation of markers to indicate and distinguish death due to alcoholic ketoacidosis, diabetic ketoacidosis and hyperosmolar hyperglycemic state using post-mortem samples. Forensic Science International, 214(1-3), 142-147. PubMed