A Case of Diabetic Ketoacidosis With Persistent Alkalosis

Diabetic ketoacidosis (DKA) is an emergent complication of diabetes. Patients with DKA typically have an arterial pH of 7.30 or lower, caused by the overproduction of β-hydroxybutyric and acetoacetic acids. We present a case of a 24-year-old male with a history of uncontrolled type 1 diabetes mellitus, noncompliance, and gastroparesis who presented to an emergency department with nausea, nonbilious vomiting, and abdominal pain. The physical exam was remarkable for dry mucous membranes, tachycardia, and mild diffuse abdominal tenderness. Initial bloodwork indicated hyperglycemia, increased levels of beta-hydroxybutyric acid, and an elevated anion gap; however, the arterial pH was alkalotic. This led to the suspicion of a combined acid-base disturbance, where profuse vomiting resulted in alkalosis, masking the expected acidosis. The patient was started on intravenous fluids and an insulin drip and was subsequently admitted to the medical intensive care unit. He left the hospital against medical advice two days later. This case is notable because the patient met all the criteria for DKA yet exhibited an alkalotic pH. It highlights the necessity of using the entire clinical picture and not solely relying on laboratory values when diagnosing and treating disease.