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Thanks for sharing! Bart B.E.P.B. Ballieux PhD, Laboratory Specialist Clinical Biochemistry and Endocrinology Department KCL, E2-P. Leiden University Medical Centre, P.O.box 9600, 2300RC Leiden Tel: +3171-5262165/62278 Fax: +3171-5266753 email: [log in to unmask]<mailto:[log in to unmask]> P Please consider the environment before printing this e-mail From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri Sent: maandag 23 april 2018 17:44 To: [log in to unmask] Subject: Re: A brain teaser case The patient was admitted to ICU for the management of severe non-diabetic ketoacidosis and dehydration. There differential diagnosis for severe ketoacidosis: 1. Diabetic ketoacidosis: she was not diabetic HbA1c 32 mmol/mol 2. Alcoholic ketoacidosis: patient denies drinking, LFTs were unremarkable and blood alcohol < 100 mg/L 3. Dietary induced ketoacidosis Dietary history was the interesting bit, she was on very low carbohydrate high fat diet regime (Atkins type diet) in order to lose weight for the past 5 months. My advice was to start her on 10% dextrose and insulin infusion in order to switch off the ketogenic process triggered by relative insulin deficiency due to release of counter-regulatory hormones (the cortisol was massively elevated). Also to fill her intravascularly with Hartmann's solution and replace potassium and phosphate losses. She responded nicely achieving normal acid base status within the next 24 hours. I haven't seen such a severe ketoacidosis due to starvation only, in this case Atkins very low carb ketogenic diet have accentuated the ketoacidosis to a severe life threatening degree. I could only find one case report similar to this case: A life-threatening complication of Atkins diet Chen, Tsuh-Yin;Smith, William;Rosenstock, Jordan L;Klaus-Dieter Lessnau The Lancet; Mar 18-Mar 24, 2006; 367, 9514 Thanks for your interest in this case, hope it helps identifying and managing similar cases. Best regards, Mohammad Dr. M. A. Al-Jubouri MBChB, FRCP Edin, FRCPath Consultant Chemical Pathologist Clinical Director of Pathology St. Helens & Knowsley Teaching Hospitals [Description: Description: Description: HSJ logo (2)] From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri Sent: 23 April 2018 16:05 To: [log in to unmask] Subject: Re: A brain teaser case Further tests/questions asked: - Paracetamol <10 mg/L - Lipids and total protein were normal. - TFTs normal - No short bowel or diarrhoea - Urinary organic acids not done - HbA1c 32 mmol/mol - Methyl alcohol?? I have mentioned toxic alcohols were negative Hint: The clue is always in the history rather than further tests!! Regards Mohammad Dr. M. A. Al-Jubouri MBChB, FRCP Edin, FRCPath Consultant Chemical Pathologist Clinical Director of Pathology St. Helens & Knowsley Teaching Hospitals [Description: Description: Description: HSJ logo (2)] From: Mohammad Al-Jubouri Sent: 23 April 2018 15:29 To: Mohammad Al-Jubouri; [log in to unmask]<mailto:[log in to unmask]> Subject: RE: A brain teaser case Here are the additional questions/tests some of you have asked for: - Not on NSAID or SGLT2 inhibitors - No diarrhoea - Toxic alcohols negative, I have mentioned EG < 25 mg/L - Lactate method measures L-lactate - Blood pH 7.09, PCO2 1.76 kPa - serum salicylate <10 mg/L - Urine acidic pH <5.0, full of ketones, see blood ketones 6.5 mmol/L - Serum cortisol 3200 nmol/L, stress response Happy to supply any further details required. Dr. M. A. Al-Jubouri MBChB, FRCP Edin, FRCPath Consultant Chemical Pathologist Clinical Director of Pathology St. Helens & Knowsley Teaching Hospitals [Description: Description: Description: HSJ logo (2)] From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri Sent: 23 April 2018 14:31 To: [log in to unmask]<mailto:[log in to unmask]> Subject: A brain teaser case A conundrum for the mailbase collective: A 60 year old woman presented with gradual deterioration over past 5 days and presented with feeling sick and being generally unwell. She has a history of chronic back pain and hypertension but has been working and independent and not a drinker. Examination was only remarkable in finding high respiratory rate, tachycardia, dehydration and acetone smell. Biochemical tests revealed: Sodium 146 mmol/L Chloride + 121 Potassium - 3.3 Bicarb - <5.0 Anion gap + 28.3 Ketones +6.5 mmol/L Lactate 1.5 mmol/L S.Osmolal + 329 Urea 3.2 EGFR - 52 Creatinine + 101 AKI Stage 1 CRP + 16 R. Glucose 7.7 mmol/L HbA1c 32 mmol/mol Se Alcohol <100 mg/L EG <25 mg/L ALT 38 Amylase - 27 ALP 123 Sodium 146 Bilirubin 11 Albumin + 55 WCC +14.5 Hb +180 INR +1.6 D-dimer 329 (Ref <500) What are your thoughts? Regards, Mohammad Dr. M. A. Al-Jubouri MBChB, FRCP Edin, FRCPath Consultant Chemical Pathologist Clinical Director of Pathology St. Helens & Knowsley Teaching Hospitals [Description: Description: Description: HSJ logo (2)] --------------------------------------------------------------------------------------------------------------------- Virus Scanned and Verified by St Helens and Knowsley Health Informatics --------------------------------------------------------------------------------------------------------------------- DISCLAIMER: This email may contain confidential and/or proprietary information some or all of which may be legally privileged. It is for the intended recipient only. If any addressing or transmission error has misdirected this email, please notify the author by replying to this e mail and destroy any copies. If you are not the intended recipient you must not use, disclose, distribute, copy, print, or rely on this email. 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