Ketogenic Diet Induced Severe Diabetic Ketoacidosis in an Elderly With Undiagnosed Diabetes

Introduction: A ketogenic diet is a high-fat, low carbohydrate with adequate amounts of protein diet that is well known and extensively utilized as a nonpharmacological intervention for weight loss and glycemic control. However, a very low level of carbohydrates and high amounts of lipid and protein can lead to ketosis and may trigger ketoacidosis in a high-risk population. Clinical Case: A 74-year-old Caucasian male with hypertension and hyperlipidemia, who presented with shortness of breath, nausea, vomiting, generalized abdominal pain, polydipsia, and polyuria for few days. The patient denied a prior history of diabetes. His family history is significant for rheumatoid arthritis in his mother with no history of diabetes in the family. He reported that he had been on a ketogenic diet for a month and had lost 22 pounds. His BMI is 29.3 kg/m(2) on admission. His physical examination was notable for tachycardia with extremely dry mucous membrane. He had fast and deep respirations that were suspicious for diabetic ketoacidosis. His bedside VBG showed pH6.8, pCO2 27 mmHg, and HCO3 5 mmol/L. Other laboratory findings revealed glucose 800 mg/dL, anion gap 39, lactic acid 9 mmol/L, bicarbonate 4 mmol/L, which indicated severe diabetic ketoacidosis. He received a 3 liters of NSS bolus and an insulin drip was started. With a worsening mental status, and increasing in his respiratory drive, endotracheal intubation was performed. DKA protocol was initiated and the patient was then admitted to the ICU for close monitoring. The patient was later stabilized and improved and was extubated. Diabetes ketoacidosis resolved after 2 days. Hemoglobin A1c found to be at 12% which revealed that the patient might be undiagnosed for diabetes after all. Later on, troponin was found to be trending up respectively. A small non-ST elevation microinfarction was suspected. Cardiology was consulted. He was subsequently taken to the cardiac catheterization lab. One DES stent was placed in the mid circumflex successfully. The patient was discharged with Lantus 40 units at nighttime and Lispro 5 units TID premeal on the day seventh of admission. The patient was discharged to home with home health care for diabetic education and teaching insulin administration. Conclusion: Even though the ketogenic diet is considered a safe nutrition option and there is multiple clinical evidence support the use of the ketogenic diet in diabetes, obesity, and endocrine disorders, it may cause serious side effects, including ketoacidosis. An accumulation and elevation of ketone levels have known to be associated with increased oxidative stress and inflammatory process which rising the risk of vascular inflammation and other comorbidities. Therefore, physicians should be cognizant of the complications and risks, and benefits of the ketogenic diet. Risks and benefits of the ketogenic diet should be discussed with patients before initiation of this diet.