Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Severe Euglycemic Ketoacidosis Induced by Ketogenic Diet

Sana Ahmad, Jacob Schwartz*

Lenox Hill Hospital, Department of internal Medicine New York, NY

Abstract: Ketogenic diets are diets based on restricted carbohydrate intake in favor of foods high in protein, fats, and fiber. As a result, blood sugar levels tend to drop. This process ultimately leads to the production of ketones which are then used by the body for fuel resulting in ketonemia. This case report focuses on a non-obese male with no past medical history who presented with several days of nausea and vomiting after recently starting himself on a ketogenic diet. Upon admission, the patient was found to have an increased anion gap metabolic acidosis with a gap of 37. Secondary causes of elevated anion gap metabolic acidosis were ruled out. The patient was appropriately fluid resuscitated with a dextrose containing fluid with improvement in symptoms and closure of the gap. Underlying hepatic steatosis may contribute to the development of euglycemic ketoacidosis in those on a low carbohydrate diet. A minimum amount of carbohydrates (approximately 100 grams) may prevent ketosis in these patients. It is important for providers to understand and recognize that severe euglycemic ketoacidosis can be a complication of a ketogenic diet.

Keywords: Euglycemic ketoacidosis, ketogenic diet, increased anion gap metabolic acidosis. Ketonemia

Received May 09, 2020; Revised June 11, 2020; Accepted June 18, 2020

Citation: Sana Ahmad, Jacob Schwartz, Severe Euglycemic Ketoacidosis Induced by Ketogenic Diet. American Journal of Medical Case Reports, 8 (10). 335-336. January 2020. doi:10.12691/ajmcr-8-10-4

1. Introduction

Ketogenic diets are based on restricted carbohydrate intake in favor of foods high in protein, fats, and fiber. As a result, blood sugar levels tend to drop stimulating the pancreas to release glucagon leading to the conversion of glycogen to glucose. After glycogen stores run out, the liver begins to break down fats and proteins into glucose and ketones via gluconeogenesis and ketosis. Ultimately, this is the mechanism through which we see starvation ketonemia. There are a few case reports in literature about ketogenic diet causing life threatening ketoacidosis. [1,2,3,4] However, the patient population in these case reports were either females who were lactating or patients who were hyperglycemic at the time of presentation. Currently one similar case exists in a female, of similar age, with no past medical history who presented with diet induced ketoacidosis, although with hyperglycemia. [5] Here we report a case of a 50-year-old male with no past medical history who presented with an euglycemic elevated anion gap metabolic acidosis in the setting of a low carbohydrate diet.

2. Case Presentation

A 50-year-old male with no past medical history-on no medications, a remote past history of alcohol abuse (no recent use in 13 years) and normal BMI (24) presented to the emergency department with 4-day history of nausea and vomiting. On presentation, he was afebrile and tachycardic to 110, with a blood pressure of 105/45 and breathing 18 breaths per minute, saturating 100% on room air. On physical exam, the patient had some mild central obesity and tenderness to palpation over right lower abdomen. Shown in Table 1 are his pertinent admission labs. His VBG was notable for a pH of 7.2 and PCo2 of 19. A negative urine toxin screen, non-detectable methyl alcohol and ethylene glycol levels and the osmolar gap helped to rule out other causes of the elevated anion gap.

CT abdomen and pelvis with contrast showed a distended gallbladder believed to be secondary to fasting as well as hepatic steatosis. On subsequent history, it was revealed that the patient had started a ketogenic diet one week prior to onset of symptoms. His diet consisted of a standard ketogenic diet which consisted of approximately 80% protein, and 20% fats, with no carbohydrate intake. The patient was monitored closely in an ICU stepdown unit. He was appropriately fluid resuscitated with improvement in his symptoms and resolution of lab abnormalities.

3. Discussion

This case was unique as this patient was a presumably healthy male with no significant medical history. Additionally, this patient presented with euglycemic ketoacidosis whereas in Slade and Ashurst’s case the patient was hyperglycemic to 163 on presentation to the emergency department. One possible hypothesis is that the patient was more easily predisposed to developing a severe ketoacidosis given his underlying hepatic steatosis which may have resulted in decreased glycogen stores, however, no clear link has been established to date. It may be pathophysiologically similar to pregnancy or lactation where the body has lower glycogen stores, increased insulin resistance, and increased lipolysis leading to a state of ketosis. [6]

Table 1. Laboratory data

4. Conclusion

Severe ketoacidosis is a life-threatening condition which can cause cardiac arrhythmias and even death. The etiology of ketoacidosis can vary and proper recognition of underlying cause is important as treatment modalities are different. It is important to educate patients on ketogenic diets and the complications associated with it. As little as 100 grams of carbohydrates might prevent ketosis and may be clinically indicated in some medical conditions such as epilepsy, [7] and obesity. It is important to recognize in a patient’s history that this may be their only contributing factor to the development of anion gap metabolic acidosis.

References

[1]   | Von Geijer L, Ekelund M. Ketoacidosis associated with low-carbohydrate diet in a non-diabetic lactating woman: a case report. J Med Case Rep. 2015; 9: 224. Published 2015 Oct 1.
[2]   | Freeman, TF. Et al. Acute intractable vomiting and severe ketoacidosis secondary to the Dukan Diet©. J Emerg Med. 2014 Oct;47(4):e109-12. Epub 2014 Aug 22.
[3]   | Sloan G. Et al. A rare cause of metabolic acidosis: ketoacidosis in a non-diabetic lactating woman. Endocrinol Diabetes Metab Case Rep. 2017 Sep 4; 2017. pii: 17-0073. eCollection 2017.
[4]   | Shah Pankaj. Isley William. Ketoacidosis during a Low-Carbohydrate Diet. January 5, 2006. N Engl J Med 2006; 354:97-98.
[5]   | Slade, S., & Ashurst, J. (2020). Diet-induced Ketoacidosis in a Non-diabetic: A Case Report. Clinical Practice and Cases in Emergency Medicine, 4(2). Retrieved from https://escholarship.org/uc/item/2pv0f6sp.
[6]   | Zhou, C. Byard, RW. Septic ketoacidosis – a potentially lethal entity with renal tubular epithelial vacuolization. J of Forensic Sci. 2017; 62 122-12.
[7]   | Kossoff EH, Zupec-Kania BA, Auvin S, et al. Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open. 2018; 3(2): 175-192. Published 2018 May 21.