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Diabetic masquerading as ketoalkalosis Sri Lanka Journal of Child Health , 2020; 49 (3): 288-289

Diabetic ketoacidosis masquerading as ketoalkalosis

*H S Rajani 1, Doddaiah Narayanappa 2, S N Prashanth 2, C Chandrashekhar 3

Sri Lanka Journal of Child Health , 2020; 49 (3): 288-289 http://dx.doi.org/10.4038/sljch.v49i3.9150 (Key words: Child, diabetic mellitus, ketoacidosis, ketoalkalosis)

Introduction bodies. Arterial blood gas (ABG) was suggestive of (DKA) occurs due to metabolic with a pH of 7.58 with accumulation of acetoacetic and β-hydroxybutyric of 34.5 and (BE) of 11.5. acids. It is a hallmark acute metabolic complication Chest x-ray was within normal limits. of mellitus having the triad of Ultrasonogram (USG) of abdomen was normal. uncontrolled hyperglycaemia, metabolic Child was managed according to standard DKA and increased total body concentration. protocol. Repeat ABG done after 6 hours still There are several publications reporting the showed . Repeat presence of combined acid-base disorders in DKA 1- were found to be within normal limits. Repeat ABG 3. A rare but recognized metabolic complication is after 24 hours was normal. Child improved and was diabetic ketoacidosis with alkalaemia discharged and is on regular follow up. (ketoalkalosis). Ketoalkalosis is ketoacidosis in which the acidosis is obscured by a coexisting Discussion alkalosis 1. We are hereby reporting a case of DKA Although criteria for the presence of diabetic with frank metabolic alkalosis in a 7 year old boy. ketoalkalosis (DKALK) are not generally established, normal pH with high (Delta Case report ratio = (change in ) / (change in A 7‐year‐old boy presented with typical symptoms bicarbonate) of > 1.2 or serum bicarbonate >24 of ‐dependent diabetes mellitus with mEq/dL or high pH indicates combined metabolic polydipsia, polyphagia and polyuria for 1 month. He alkalosis 1. This was originally described in 1959 4 was the first child of a non-consanguineous marriage but later on Bleicher described the disorder as with a birth weight of 1.4 kg with no other DKALK 5. Since then more than 30 cases has been significant antenatal, natal or postnatal history and published in the literature 3,6 , but there are few case with normal developmental milestones. There was reports in the paediatric population. Some authors no history of ingestion of chronic medications. On do not accept the term DKALK because the admission, child was afebrile and metabolic alkalosis occurs secondary to contraction haemodynamically stable except for a tachycardia of alkalosis due to and and/or 114 bpm. Systemic examination was unremarkable. use or due to alkali ingestion, No acidotic breathing was noted. On admission, the hypercortisolism due to steroids or Cushings capillary blood gas (CBG) was high, random blood disease 1. Severe can also result sugar (RBS) was 405mg/dl. C-peptide was low with in alkalaemia. 0.38, HbA1C was high being 12.6, serum electrolytes showed of 127meq/l, Children with type 1 diabetes can present with chloride of 96meq/l and potassium was 5meq/l and ketoacidosis masked as alkalosis but still requiring renal functions were normal. Urine showed ketone ketoacidosis treatment 7,8 . A case of diabetic ______ketoacidosis in a seven year old child presenting 1Assistant Professor, 2Professor, 3Associate with frank alkalemia (pH, 7.58) instead of acidaemia Professor, Department of Paediatrics, JSS Medical (pH < 7.35) is discussed here. In this child, severe College,, JSS Academy of Higher Education and vomiting resulted in depletion and Research, Mysore, India. hypovolaemia, causing bicarbonate reabsorption *Correspondence: [email protected] resulting in an alkalemic state may be the cause of alkalosis despite the presence of ketoacids. orcid.org/ 0000-0001-5578-8729 (Received on 10 October 2018: Accepted after Although DKA is a straightforward diagnosis with revision on 16 November 2018) rapid evaluation of electrolytes, pH, , and The authors declare that there are no conflicts of ketone tests, it is necessary to calculate the anion gap interest (AG) and delta ratio (DR) as well. Recognition of Personal funding was used for the project. DKA may be obscured unless the AG, DR, and are considered because the pH and Open Access Article published under the Creative bicarbonate may be near normal or even elevated 1. The entity of diabetic ketoalkalosis is easily Commons Attribution CC-BY License

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Diabetic ketoacidosis masquerading as ketoalkalosis Sri Lanka Journal of Child Health , 2020; 49 (3): 288-289

misdiagnosed and is probably more common than is generally recognized. Recognition of alkalaemia 4. Webster GD, Touchstone JC, Suzuki M. and its underlying cause will lead to institution of Adrenocortical hyperplasia occurring with appropriate treatment. Failure to recognize the metastatic carcinoma of prostate: report of disorder may hinder prompt diagnosis of DKA as a case exhibiting increased urinary well as investigation for the cause of metabolic and glucocorticoid excretion. alkalosis. Journal of Clinical and 1959; 19 (8), 967–79. This case report highlights the importance of clinical https://doi.org/10.1210/jcem-19-8-967 correlation of investigations and interpretation of PMid: 13843339 ABG in recognizing the coexisting acid-base disorder to achieve prompt diagnosis and 5. Bleicher S. not always acidosis: management of DKA. In case of DKA with normal “heartburn” can be relevant. Diabetes to high pH or abnormal delta ratio, DKALK must be Outlook. 2, 3–4, (1967). considered and the underlying cause of alkalosis should be actively looked for although treatment of 6. Huggins EA, Chillag SA, Rizvi AA, Moran diabetic ketoalkalosis does not differ from that of RR, Durkin MW. Diabetic ketoalkalosis in pure DKA. children and adults. Southern Medical Journal 2014; 107 (1), 6–10. References https://doi.org/10.1097/SMJ.00000000000

00040 1. Hirooka N, Koga A, Fujii H, Takeo H, PMid: 24389778 Sato K, Matsukuma S, et al. Developing diabetic ketoalkalosis in a patient with Cushing disease. Diabetes Management 7. Svart MV, Voss TS, Bayat M, Madsen LR, 2017; 7(4): 322–6. Andersen LT, Poulsen PL, et al. Rare presentations of ketoacidosis: Diabetic 2. Elisaf MS, Tsatsoulis AA, Katopodis KP, ketoalkalosis and ketoacidosis secondary Siamonpoulos KC. Acid-base and to fasting and muscular dystrophy. Clinical electrolyte disturbances in patients with Diabetes 2015; 33 (1), 37–9. diabetic ketoacidosis. Diabetes Research https://doi.org/10.2337/diaclin.33.1.37 and Clinical. Practice 1996; 34 (1), 23–7. PMid: 25653472 PMCid: PMC4299743 https://doi.org/10.1016/S01688227(96)01 332-0 8. Kumar V, Nanavati SM, Komal F, et al. Ketoalkalosis: Masked presentation of 3. Tanahashi H, Yasuda K, Hayashi M et al. diabetic ketoacidosis with literature Acid-base disturbances in Japanese review. Journal of Endocrinology and patients with diabetic ketoacidosis. Journal Metabolism 2017; 7(6): 194–6, of the Japan Diabetes Society 2006; 49 , https://doi.org/10.14740/jem472w 259–65.

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