A 37-year old man, with a medical history of obesity, insulin-dependent type 2 diabetes mellitus and asthma was admitted to the emergency room. For the last couple of days, he had been sick with fever, nausea, vomiting, weakness, and shortness of breath. He did not use any alcohol or party drugs. Today, when his girlfriend returned home, she met him in a confused state and called an ambulance. At the emergency room, physical examination shows decreased consciousness, a temperature of 38.4 degrees Celsius, blood pressure of 141/78 mmHg, heart rate of 116/min, and a respiratory rate of 31/min with SpO2 of 94%. Auscultation of heart and lungs revealed no abnormalities. The arterial blood gas is presented below (TABLE 1). Furthermore, X-ray revealed no infiltrate.
Tabel 1 Arterial blood gas analysis
Tabel 2 Blood test result
L.S.F. Konijnenberg & N.H. Sperna Weiland
The correct answer is B. The arterial blood gas represents a metabolic acidosis with partial respiratory compensation. See the step-by-step analysis below.
The correct answer is B. Based on medical history and blood tests, the most likely diagnosis is diabetic keto-acidosis caused by an underlying infection in combination with poor intake, vomiting, and subsequently inadequate use of insulin.
A: This is not the correct answer. Hyperosmolar hyperglycaemic non-keto-acidosis syndrome (HHS) is defined as hyperglycaemia (>30 mmol • l-1) without ketonemia. The pH is usually within normal range. The severity of HHS is related to plasma-osmolarity. Hyperosmolar dysregulation can be accompanied by lactate-acidosis.
B: This is the correct answer. Diabetic keto-acidosis is defined as the combination of anion gap metabolic acidosis, hyperglycaemia and ketonemia. The increased lactate level might be explained by an increased anaerobe metabolism.
C: This is not the correct answer. Lactate-acidosis is defined as metabolic acidosis with high lactate level without hyperglycaemia and ketonemia. However, lactate-acidosis can be seen as part of diabetic keto-acidosis or hyperosmolar hyperglycaemic non-keto-acidosis syndrome.
D: This is not the correct answer. Alcoholic keto-acidosis is defined as metabolic acidosis with ketonemia and a normal to slightly elevated glucose level. Patients seldomly present with hyperglycaemia.
- Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism. 2016;65(4):507-521.