ESPE Abstracts

Introduction: Non-diabetic ketoacidosis occurring with hyperglycaemia causes diagnostic dilemma in the emergency department. Biochemistry mimics diabetic ketoacidosis [DKA], the proposed mechanism is ketosis from reduced carbohydrate intake, with stress hyperglycaemia from acute illness.

Case Description: A 1 year old boy presented to the emergency department with a short history of fever and reduced oral intake. Initial venous blood gas [VBG] revealed a metabolic acidosis pH 7.3, glucose of 17mmol, bicarbonate 16.4 mmol/l with capillary ketones of 5.4mmol; meeting criteria for mild DKA. DKA protocol was initiated however prior to fluid administration an opportunistic repeat VBG revealed spontaneously improved result of pH 7.31, glucose of 12.3mmol and ketones of 3.5mmol. This prompted de-escalation of treatment from local DKA protocol and a diagnosis of stress hyperglycaemia with ketoacidosis.

Discussion: Whilst ketosis after periods of starvation is common in the paediatric population, accompanying acidosis with significant hyperglycaemia is less commonly encountered. This case highlights that stress hyperglycaemia may occur in the setting of other causes of metabolic acidosis. The biochemical similarities can lead to misdiagnosis of DKA and, therefore, inappropriate treatment with insulin. Thorough history is extremely important to ascertain preceding osmotic symptoms and aid diagnostic uncertainty.

Conclusion: To our knowledge this is the first case report of non-diabetic ketoacidosis with significant hyperglycaemia in the paediatric population. The aimof this report is to highlight stress-hyperglycaemia as a differential diagnosis for ketosis, hyperglycaemia and acidosis when children present with atypical history and to summarise investigation and treat metabolic derangement. Correct diagnosis is important to prevent therapeutic inertia.