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Thanks to all replies

 

Most of you agree that this represents a case of alcoholic ketoacidosis but find the accompanying lactic acidosis atypical. There are at least 3 further samples showing less severe metabolic derangement during her therapy with saline infusion, 10% dextrose/insulin infusion and pabrinex.  This is therefore a genuine metabolic derangement and citrate contamination is not to blame. She needed potassium, magnesium and phosphate supplements as you might expect with treated metabolic acidosis. Her biochemical parameters quickly recovered back to normal within 24 hours. The hypochloraemia due to vomiting has exaggerated the calculated anion gap. The osmolal gap can probably be expalined by ethanol (30 mmol) + lactate (15 mmol) and B-OH-Butyrate (15 mmol), but I am still waiting for toxic alcohols screen. 

 

Learning point: Profound hyperlactataemia can accompany alcoholic ketoacidosis.

 

Regards

 

Mohammad

 

Mohammad Al-Jubouri <[log in to unmask]> wrote:

Dear All

 

A 62-year-old lady presented with short history of vomiting and breathlessness. Physical examination was unremarkable!!, CXR normal. A biochemical profile showed:

 

U/E: Na 143 mmol/L, K 4.6 mmol/L, urea 8.3 mmol/L, creatinine 150 umol/L, chloride 87 mmol/L, bicarbonate 8.0 mmol/L.

LFTs: Bilirubin 12 umol/L, ALP 102 IU/L, ALT 39 IU/L, AST 67 IU/L, GGT 42 IU/L, albumin 46 g/L.

Others: glucose 11.2 mmol/L, CK 67 IU/L, adjusted calcium 2.24 mmol/L, phosphate 3.44 mmol/L, osmolality 361 mOsm/kg, CRP < 5 mg/L,  INR 1.0

 

Acid base status: pH 7.13 kPa, PCO2 2.7 kPa, PO2 11.2 kPa

Anion gap 54 mmol/L

Osmolal gap > 50 mmol/L

Lactate 15 mmol/L

Beta-hydroxybutyrate 15 mmol/L

Serum alcohol 136 mg/dL

Toxic alcohols screen: to follow.

 

Drug history: None.

Alcohol drinking: ++++

 

Impression: Profound combined lactic/ ketoacdosis.

 

Question: can all this be due to alcohol only? have you had any experience with a similar case, would be grateful for your comments.

 

regards

 

Mohammad

 

 

 

Dr. M A Al-Jubouri
Consultant Chemical Pathologist

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Dr. M A Al-Jubouri
Consultant Chemical Pathologist

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