A case of alcoholic ketoacidosis with type 2 diabetes mellitus

A 64-year-old man with a history of diabetic coma was admitted for loss of consciousness and convulsions with chronic alcohol abuse, and recent binge drinking followed by abrupt cessation of alcohol and loss of appetite. Previously diabetic ketoacidosis was suspected because of his history of diabetic coma. His metabolic acidosis was corrected quickly by hydration and administration of insulin without sodium bicarbonate. Based on mild elevation of blood glucose and HbA1c, and increasing serum ketone bodies with elevation of the ratio of β-hydroxybutyric acid to acetoacetic acid, we diagnosed his case as alcoholic ketoacidosis(AKA) with type 2 diabetes mellitus. Pathophysiologically, ethanol abuse, acute starvation, and dehydration directly cause AKA. Decreased NAD and glycogen by excessive alcohol intake and suppressed glycogenesis suppress insulin secretion. β oxidation stimulation by low insulin causes increasing levels of ketone bodies and progression of metabolic acidosis. Hydration with electrolytes and administration of glucose are the basic treatment for AKA patients without diabetes. AKA with delay in treatment or marked metabolic acidosis is frequently fatal. AKA is thus an important differential diagnosis among diabetes patients with a history of chronic alcohol abuse and metabolic acidosis.