Ketogenic Diet-Induced Diabetic Ketoacidosis in a Young Adul
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Ketogenic diet, a very low-carbohydrate diet and high-fat diet, has emerged as a popular approach for weight reduction, particularly in young adults. However, a serious but rare complication of the ketogenic diet is ketoacidosis associated with low carbohydrate intake, which should be cautiously monitored in people with a predisposition to the condition.

A 22-year-old Thai woman with an unremarkable past medical history presented to the emergency department with an acute onset of dyspnea of 2 days' duration. She was unable to tolerate any food or drink since the symptoms started. On examination, her vital signs included temperature 38°C, pulse rate 110 bpm, blood pressure 110/80 mmHg, and respiratory rate 32/minute with a kussmaul breathing pattern. Other physical examinations were unremarkable except for severe dehydration. The initial testing revealed capillary blood glucose of 356 mg/dL, serum bicarbonate of 4.8 mEq/L, arterial pH of 7.15, and a serum beta-hydroxybutyrate level of 6.65 mmol/L, while the lactate level was normal. The urinalysis showed glucosuria and ketonuria. A diagnosis of new-onset diabetes and diabetic ketoacidosis (DKA) was established. However, the type of diabetes was undetermined at that time. Fasting C-peptide level and islet autoantibodies were sent to evaluate for type 1 diabetes.

She was admitted to the intensive care unit and treated with intravenous saline, intravenous insulin infusion, and electrolyte repletion. Blood glucose levels and metabolic acidosis improved. Oral intake and subcutaneous insulin were initiated two days later. Despite a BMI of 22.3 kg/m2, the patient felt that she needed to lose weight. A week prior, she initiated an intensive weight management regimen including a ketogenic diet. She had restricted her carbohydrate intake to less than 15 grams per day 4 days. She denied participating in a heavy exercise which could lead to dehydration. Other precipitating factors of DKA were not identified.

After 6 days of hospital admission, she was discharged with multiple daily injection (MDI) insulin therapy without further complications. One week later, the results of special investigations for identifying the type of diabetes showed C-peptide level 0.2 ng/mL, anti-GAD 8.79 U/mL, and anti-IA2 130.95 U/mL, which confirmed the diagnosis of type 1 diabetes in this patient.