Hypernatremia in Diabetic Ketoacidosis: Rare Presentation and a Cautionary Tale

Hyponatremia in diabetic ketoacidosis (DKA) is common and can be due to several reasons. However, hypernatremia in DKA is rare and can be life-threatening. Its exact etiology is not clear and several mechanisms related to water deficit from inadequate oral intake and free water loss that supersedes the electrolyte loss through diarrhea or vomiting have been proposed. Treating the DKA more aggressively than the hypernatremia itself, choosing a hypoosmolar fluid, and switching to D5-0.45% saline, when glucose has decreased, are some of the vital considerations for the management of hypernatremia in DKA. We present a 44-year-old male patient with an unclear history of DKA with unusually severe hypernatremia that gradually responded to aggressive management of DKA with rigorous IV hydration and the above-mentioned strategies.