Presentation of Diabetic Ketoacidosis (DKA)
DKA typically presents with the classic triad of hyperglycemia (blood glucose >250 mg/dL), metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L), and elevated ketones, though euglycemic DKA (glucose <250 mg/dL) is increasingly recognized and occurs in approximately 10% of cases. 1, 2
Primary Clinical Symptoms
The most common presenting symptoms evolve rapidly, usually within less than 24 hours: 3, 4
- Polyuria and polydipsia are the most frequently reported symptoms 4
- Polyphagia with paradoxical weight loss occurs as the body breaks down fat and muscle for energy 3
- Gastrointestinal symptoms including nausea, vomiting, and abdominal pain are common, with up to 25% experiencing coffee-ground emesis; abdominal pain can be severe enough to mimic an acute surgical abdomen 1, 3
- Severe fatigue, weakness, and malaise are frequently reported 1, 3
- Preceding febrile illness is commonly reported, as infection is the most frequent precipitating factor occurring in 52-69% of cases 3
Physical Examination Findings
Key physical findings that indicate severity and guide management include:
- Kussmaul respirations (deep, labored breathing) indicate severe metabolic acidosis and are a hallmark sign 1, 3
- Signs of severe dehydration including poor skin turgor, dry mucous membranes 1, 3
- Tachycardia and hypotension from volume depletion 1, 3
- Altered mental status ranging from full alertness to confusion, drowsiness, or profound lethargy; severe obtundation or coma is less common but can occur depending on severity 1, 3
- Normothermia or hypothermia may be present even with underlying infection, with hypothermia being a poor prognostic sign 1
Diagnostic Laboratory Criteria
The American Diabetes Association diagnostic criteria include: 1
- Blood glucose typically >250 mg/dL, though euglycemic DKA can occur 1
- Arterial pH <7.3 (severe DKA: pH <7.00) 1
- Serum bicarbonate <18 mEq/L (severe DKA: <10 mEq/L) 1
- Elevated anion gap >10-12 mEq/L 1, 2
- Positive ketones in serum and urine; β-hydroxybutyrate measurement is preferred for diagnosis and monitoring 1
Special Consideration: Euglycemic DKA
A critical pitfall is missing euglycemic DKA, where glucose levels are <250 mg/dL despite meeting other criteria for DKA. 1, 2
This variant occurs in approximately 10% of DKA cases and is associated with: 1, 2, 5
- SGLT2 inhibitor use (increasingly common cause) 1, 2
- Pregnancy 1, 5
- Reduced food intake with continued insulin use 1, 6, 5
- Alcohol use 1, 5
- Liver failure 1, 5
Patients with euglycemic DKA present with the same clinical symptoms—nausea, vomiting, abdominal pain, Kussmaul respirations, dehydration, and altered mental status—but normal glucose levels can mislead clinicians if ketone levels are not obtained. 1, 6
Common Precipitating Factors
Identifying the precipitating cause is essential for management: 1, 7
- Infection (most common: 52-69% of cases, particularly urinary tract infection and pneumonia) 1, 3, 7
- New-onset type 1 diabetes 1
- Insulin omission or inadequate insulin therapy 1, 7
- Myocardial infarction or cerebrovascular accident 1, 7
- Drug use (corticosteroids, thiazides, sympathomimetic agents) 1
- Alcohol abuse 1
- Pancreatitis 1
Clinical Pearls and Pitfalls
The most important pitfall is failing to check ketone levels in patients with diabetes who present with acidosis but normal or mildly elevated glucose, thereby missing euglycemic DKA. 6, 5
- DKA evolves rapidly (usually <24 hours), distinguishing it from hyperosmolar hyperglycemic state which develops over days to weeks 1, 3
- Nitroprusside-based ketone tests (standard urine or blood tests) do not measure β-hydroxybutyrate, the predominant ketone in DKA; β-hydroxybutyrate measurement is preferred 1
- The presentation is highly variable, ranging from mild hyperglycemia and acidosis to severe hyperglycemia, dehydration, and coma, requiring individualized assessment 8