A 35-year-old male was found in his house with reduced GCS lying on the floor. He lives alone and was not seen by a member of his immediate family for at least 3 days and is not a known diabetic patient. His admission blood sample clearly indicates DKA & rhabdomyolysis as follows:
Sodium - 128
Potassium 4.8
Urea + 26.3
Creatinine + 398
CK + 23844
R. Glucose + 59.0
Bicarb - <5.0
Chloride 98
pH 6.876
Anion gap + 34.8
Lactate 3.0
Measured S.Osmolal ity + 379
Calculated
Osmolal gap = 37 mosm/L
Because of the high osmolal gap, even for a DKA, and the obscure history, a sample was analysed for ethanol, methanol & ethylene glycol, all were not detected, however his serum acetone was 271 mg/L and B-hydroxybutyrate 1358 mg/L. So the big osmolal gap could be accounted for by the ketones in this case. I was not aware that DKA could produce such a big osmoal gap due to ketones only, but I suspect that in a late presenting DKA like this case, it reflects the severity of ketoacidosis as it proceeded without treatment for > 48h at least.
Your thoughts/experience are welcome.
Best regards
Mohammad
Dr. M A Al-Jubouri, MB ChB, MSc, FRCP Edin, FRCPath