A 45 year old male with a history of alcohol use disorder, diabetes on insulin, glipizide, and empagiflozin presents with chest pain and shortness of breath. 3 days ago, he drank 20 beers and then started vomiting. Last night, he developed chest pain and headache. Today, he has been feeling short of breath.
Vital signs: BP 126/70, HR 90, Temp 98.7F, RR 35, SpO2 99%. EKG is normal. Accucheck 182.
On exam, he is generally uncomfortable appearing and tachypneic with increased work of breathing. He has dry mucous membranes and clear lung sounds bilaterally. There is mild tenderness to palpation over the epigastric area.
Labs are notable for:
- VBG: pH 7.08, pCO2 20, HCO3 9
- BMP: Na 121, BUN 23, creatinine 1.12
- Ethanol, salicylates, and acetaminophen levels undetectable
- Lactate 1.3
- Beta-hydroxybutyrate 9.8
- Urine: 4+ ketones, normal specific gravity
Differential diagnosis includes: Euglycemic DKA, Alcoholic Ketoacidosis, Starvation Ketosis, and Toxic Alcohol Ingestion
Management:
- Started with 1L NS bolus
- Insulin infusion @ 0.1 u/kg/hr
- Thiamine, folate supplementation
- GMAWs protocol for expected alcohol withdrawal
- Critical Care consultation
Pearls:
- Symptoms of acidosis: nausea, vomiting, headache, abdominal pain, generalized weakness, Kussmaul respirations (tachypnea with belly breathing and clear lungs)
- Differential diagnosis for anion gap metabolic acidosis: uremia (high BUN/creat), lactic acidosis (sepsis/shock), ketoacidosis (DKA vs. alcoholic vs starvation), ingestion (salicylate vs. acetaminophen)
- Euglycemic DKA: a rare disorder in which glucose level is relatively normal (<250) but ketoacidosis develops
- Consider eDKA in pregnancy, type 1 diabetes, alcohol abuse, liver failure, starvation, but most notably in patients taking SGLT2 inhibitors (-“flozin”)
- Treatment: D5NS + insulin, replete K if needed
- Euglycemic DKA and alcoholic ketoacidosis can be very difficult to distinguish, as alcohol use and poor PO intake can precipitate euglycemic DKA. In anyone with diabetes presenting like the case above who is on an SGLT2 inhibitor and impaired liver function, have a low threshold to start insulin to help drive the glucose into cells once glucose >180.
References:
Gabor, KD., Cline, DM. “Acid-Base Disorders.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (73-78).
Howard RD, Bokhari SRA. Alcoholic Ketoacidosis. [Updated 2021 Dec 12]. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430922/
Mehta, A., Emmett M. “Fasting Ketosis and Alcoholic Ketoacidosis.” UpToDate. October, 2020.
Nyce, A. Byrne, R., Lubkin, C. Chansky, M. “Diabetic Ketoacidosis.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (1433-1441).
