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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:
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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
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
From: Mohammad
Al-Jubouri
Sent: 23 April 2018 15:29
To: Mohammad Al-Jubouri;
[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
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]
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
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