North Texas GME Research Forum 2023



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North Texas


Medical City Arlington


Internal Medicine

Document Type


Publication Date



diabetic ketoacidosis, ketosis


Internal Medicine | Nutritional and Metabolic Diseases


Introduction Most clinicians have heard the old adage: if it looks like a duck, walks like a duck, and quacks like a duck, it’s a duck. However, this is not always true. Ketoacidosis is a complicated physiological state resulting from fatty acid and amino acid degradation often associated with type 1 diabetics. It can also arise with excess alcoholism, pregnancy, starvation, and exercise. Diabetic, alcoholic, and starvation ketoacidosis may present similarly. Clinicians can often mistake alcoholic and starvation ketoacidosis for diabetic ketoacidosis due to its common presentation. We present a case of a young non-pregnant woman with a history of alcoholism, treated on several admissions for presumed diabetic ketoacidosis, whose ketoacidosis improved clinically with treatment targeted at starvation ketoacidosis and without the administration of insulin. Case Presentation A 31-year-old woman with a past medical history of alcoholism presented with a five-day history of diffuse achy abdominal pain and intermittent nausea and vomiting. She endorsed increased urinary urgency, fatigue, decreased appetite, and 20 pounds of unintentional weight loss. In the preceding five months, she was admitted three times with similar symptoms and was diagnosed with diabetic ketoacidosis. She was treated with and discharged on insulin each visit. She was initially compliant with her home insulin regimen but stopped taking it due to recurrent hypoglycemia. Her workup was significant for a blood glucose of 240 mg/dL, an anion gap of 15 mmol/L, and an elevated serum beta-hydroxybutyrate of 26.64 mg/dL. Her hemoglobin A1C was normal at 5.5%. She was symptomatically managed with antiemetics and intravenous (IV) hydration. Crucially, her blood ketone and glucose levels normalized without insulin but with the initiation of a dextrose and water infusion and IV thiamine. She was discharged on oral thiamine, and her home insulin was discontinued. Her thiamine level was confirmed low at 51.9 nmol/L post discharge. Discussion The presence of ketoacidosis and hyperglycemia may cause clinicians to suspect diabetic ketoacidosis; however, this may be a misdiagnosis. Our patient’s initial hyperglycemia was likely multifactorial from rebound hyperglycemia after inappropriate insulin administration, stress-induced, chronic alcohol use, and starvation ketoacidosis. Our patient was initially diagnosed with pre-diabetes. She was subsequently diagnosed with diabetes mellitus type 2, with non-compliance to insulin. The diagnosis was carried forward for several encounters despite a normal hemoglobin A1C and hypoglycemia with insulin administration. This case highlights the importance of looking holistically at a patient’s case without prejudice, persuasion, or repetition of previous diagnoses without consideration of alternatives.

Original Publisher

HCA Healthcare Graduate Medical Education

It Wasn’t a Duck: A Case of the Misdiagnosis of Ketoacidosis



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