Ketogenic Diet as a Trigger for Diabetic Ketoacidosis in a Misdiagnosis of Diabetes: A Case Report

Case Presentation

A 30-year-old Caucasian man with a 2-month history of type 2 diabetes presented to the emergency department with abdominal pain, emesis with occasional coffee-ground content, and constipation of 6 days’ duration. The day before, he had presented to an urgent care center for similar complaints and was told he had a high stool burden and was prescribed an oral laxative, which he was unable to tolerate.

He was taking metformin 1,000 mg twice daily for type 2 diabetes and had also initiated lifestyle modifications, which included an intensive low-carbohydrate ketogenic diet. He had restricted his carbohydrate intake to no more than 20 g/day. His family history included type 2 diabetes in his father and type 1 diabetes in a grandparent. He reported having lost 60 lb during the past 2 months, and his current weight was 263 lb (BMI 33.5 kg/m²). Previous lipid panels were only significant for low HDL cholesterol of 33 mg/dL. Since his diabetes diagnosis, home monitoring had revealed blood glucose fluctuations between 90 and 400 mg/dL despite changes in activity and diet and initiation of medication.

His vital signs included blood pressure 159/100 mmHg, pulse 98 bpm, respiration rate 26/minutes with noted Kussmaul breathing, oxygen saturation 99%, and temperature 98.1°F. Physical examination revealed diffuse abdominal tenderness, dry mucous membranes, and an acetone-like scent on his breath. Further testing revealed the results shown in Table 1, which included positive urine ketones and glucose, elevated serum ketones, a pH of 6.97, an elevated anion gap, and a blood glucose of 424 mg/dL. A diagnosis of diabetic ketoacidosis (DKA) was established, and the patient was admitted to the intensive care unit and started on treatment with intravenous fluids, insulin, potassium, and pantoprazole.

Surgery was consulted to rule out a possible …