What are the signs and symptoms of Diabetic Ketoacidosis (DKA)?

Signs and Symptoms of Diabetic Ketoacidosis

Diabetic ketoacidosis presents with a characteristic constellation of symptoms that typically evolve over hours to days, including polyuria, polydipsia, weight loss, nausea, vomiting, abdominal pain, dehydration, weakness, altered mental status, and the distinctive Kussmaul respirations. 1

Clinical Presentation Timeline

DKA typically develops rapidly, usually within 24 hours, distinguishing it from hyperosmolar hyperglycemic state which evolves over days to weeks. 1 However, the symptomatic presentation can occasionally develop more acutely with no prior warning symptoms. 1

Cardinal Symptoms

Early Symptoms (Classic Hyperglycemia)

• Polyuria (excessive urination) 1
• Polydipsia (excessive thirst) 1
• Polyphagia (excessive hunger) 1, 2
• Weight loss 1, 2
• Weakness and fatigue 1

Gastrointestinal Symptoms

• Nausea and vomiting (occurs in up to 25% of patients) 1
• Abdominal pain (specific to DKA, not seen in HHS) 1, 2
• Coffee-ground emesis that may be guaiac positive, related to hemorrhagic gastritis 1

Progressive Symptoms (Ketoacidosis Development)

• Drowsy feeling 3
• Loss of appetite 3
• Fruity odor on breath (from acetone) 3
• Flushed face 3

Physical Examination Findings

Respiratory Signs

• Kussmaul respirations (deep, labored breathing pattern) - a hallmark sign 1, 2
• Heavy breathing in severe cases 3

Cardiovascular Signs

• Tachycardia (rapid pulse) 1, 2, 3
• Hypotension 1, 2
• Shock in severe cases 1

Volume Status

• Poor skin turgor (indicating dehydration) 1, 2
• Dehydration 1, 2

Neurological Findings

• Mental status varies from full alertness to profound lethargy or coma 1
• Clouding of sensoria 1
• Altered mental status 2
• Coma (more frequent in HHS but can occur in severe DKA) 1

Temperature

• Patients can be normothermic or even hypothermic despite infection being present, due to peripheral vasodilation 1
• Hypothermia is a poor prognostic sign 1

Severity-Based Presentation

The clinical presentation correlates with severity of acidosis:

• Mild DKA (pH 7.25-7.30): Patient typically alert 1
• Moderate DKA (pH 7.00-7.24): Patient may be alert or drowsy 1
• Severe DKA (pH <7.00): Stupor or coma more likely 1

Important Clinical Caveats

Euglycemic DKA

A critical pitfall is euglycemic DKA, where blood glucose is <200-250 mg/dL despite ketoacidosis. 1, 2 This occurs with:

• SGLT2 inhibitor use 1, 2
• Pregnancy 1, 2
• Recent insulin use 4
• Reduced food intake or very-low-carbohydrate/ketogenic diets 1, 5
• Heavy alcohol consumption 1, 4
• Chronic liver disease 4

Without checking ketone levels in these patients, the diagnosis will be missed. 6

Infection Presentation

Although infection is the most common precipitating factor (30-50% of cases), patients may not have fever due to peripheral vasodilation. 1, 7 The absence of fever does not exclude infection as a trigger.

Pediatric Considerations

In children and adolescents, DKA carries a 1-3% mortality rate, with higher risk in severe cases. 1 The same symptom constellation applies, though younger children may present more acutely.

Recognition of Early Warning Signs

Public awareness and education about these signs and symptoms is paramount for prevention, as early recognition allows intervention before progression to severe DKA. 1 Patients and caregivers should be educated to recognize:

• High blood glucose levels (>200 mg/dL) with ketones present 1
• The combination of hyperglycemic symptoms with gastrointestinal complaints 1
• Kussmaul respirations and fruity breath odor as danger signs 1