Background: In diabetic athletes, glycogen depletion can contribute to the early development of starvation ketones as is demonstrated by our patient.
Case presentation: Our patient, a 15-year-old male triathlete with type 1 diabetes for 5 years was referred to our tertiary center because of suboptimal regulation on continuous subcutaneous insulin infusion (CSII). He frequently awoke with nausea and ketosis, which was initially attributed to failure of insulin delivery. With optimalisation of administration materials and initiation of concomitant s.c. injections of a long acting insulin analogue, morning ketosis persisted on a weekly basis. After thorough examination of his insulin pump records, it stood out that ketosis developed when few carbohydrates were consumed after exercise. Rapid ketosis developed in the early morning hours when physical activity was resumed before breakfast. To rule out other metabolic causes of ketosis, the patient was admitted. During the 1st day, he performed his usual physical activity, took a last meal at 1900 h and fasted afterwards. The fasting would be stopped when ketones >1 mmol/l developed or in case of complaints. After 13 hours of fasting, ketone bodies developed in the presence of relatively normal glucose levels and normal fasting insulin levels. Serum acylcarnitines were normal and urine organic acids confirmed diabetic keto-acidosis. Our working diagnosis was ketosis due to glycogen depletion, and 2 g/kg corn starch late in the evening was added to his diet. Consecutively, no ketosis occurred.
Conclusion: In diabetic athletes, glycogen depletion can contribute to the early development of starvation ketones as is demonstrated by our patient. Therefore, glycogen replacement strategies need to be discussed with our diabetic athletes.
01 Oct 2015 - 03 Oct 2015