Is a patient with a history of alcoholism, presenting with hyperglycemia (elevated blood glucose), ketonuria (elevated ketone levels), and an anion gap metabolic acidosis, in diabetic ketoacidosis (DKA)?

Is This Patient in DKA?

No, this patient is NOT in diabetic ketoacidosis (DKA) based on the laboratory values provided—the normal pH of 7.40 excludes the diagnosis, despite the presence of hyperglycemia and elevated ketones. 1

Why DKA is Excluded

The American Diabetes Association defines DKA as requiring all of the following criteria 1, 2:

• Blood glucose >250 mg/dL ✓ (patient has 244 mg/dL—borderline)
• Venous pH <7.3 ✗ (patient has 7.40—normal)
• Serum bicarbonate <15 mEq/L ✗ (patient has 22 mEq/L—normal)
• Moderate ketonuria or ketonemia ✓ (patient has ketones 1.11)

The normal pH of 7.40 definitively rules out DKA, as acidosis (pH <7.3) is an absolute requirement for diagnosis. 1, 2

Most Likely Diagnosis: Alcoholic Ketoacidosis (AKA)

Given the patient's alcoholism history with elevated ketones (1.11), elevated anion gap (20), and normal pH, this presentation is most consistent with alcoholic ketoacidosis (AKA) rather than DKA. 1

Key Distinguishing Features of AKA vs DKA:

Alcoholic ketoacidosis is distinguished from DKA by 1:

• Plasma glucose: Ranges from mildly elevated (rarely >250 mg/dL) to hypoglycemia—this patient's glucose of 244 mg/dL fits AKA
• Clinical history: Chronic alcohol consumption with recent binge drinking or abrupt cessation 3, 4
• pH variability: While AKA can cause profound acidosis, this patient's normal pH suggests either early presentation or resolving AKA 1
• Bicarbonate: In starvation ketosis (related condition), bicarbonate is usually not lower than 18 mEq/L—this patient's bicarbonate of 22 mEq/L is normal 1

Critical Pitfall to Avoid:

Do NOT treat this patient with insulin as you would for DKA. 5 Alcoholic ketoacidosis presenting with modest hyperglycemia can be misdiagnosed as DKA, leading to inappropriate insulin administration and potentially fatal hypoglycemia. 5 One case report documented a patient with AKA and hyperglycemia who experienced hypoglycemic attack within one hour of insulin initiation when mistakenly treated as DKA. 5

Recommended Management for AKA

The mainstay of treatment for alcoholic ketoacidosis includes 3, 4:

• Aggressive IV fluid resuscitation with isotonic saline to correct hypovolemia 3, 4
• Thiamine supplementation (100 mg IV) to prevent Wernicke's encephalopathy 3, 4
• Dextrose-containing fluids once adequate thiamine is given, to provide substrate and suppress ketogenesis 3
• Electrolyte replacement, particularly potassium, magnesium, and phosphate 4
• Monitor for complications: liver dysfunction, lactic acidosis, acute pancreatitis, rhabdomyolysis 4

Additional Differential Considerations

The elevated anion gap (20) with normal pH could also represent 1:

• Compensated metabolic acidosis from chronic alcohol use
• Mixed acid-base disorder (metabolic acidosis with respiratory alkalosis)
• Lactic acidosis (common in alcoholics, check lactate level) 1
• Chronic renal failure (though typically causes hyperchloremic rather than high anion gap acidosis) 1

Obtain a complete history focusing on: recent alcohol intake pattern, last drink, dietary intake over past 48-72 hours, vomiting/diarrhea, abdominal pain, and any history of diabetes or insulin use. 3, 5