It was not until 1970 that Jenkins et al2 described a further three non‐diabetic patients with a history of chronic heavy alcohol misuse and recurrent episodes of ketoacidosis. This group also proposed a possible underlying mechanism for this metabolic disturbance, naming it alcoholic ketoacidosis. Variably severe metabolic acidosis with an increased anion gap is generally present. The main source of the large anion gap is the accumulation of acetoacetate and beta-hydroxybutyrate in blood that can be detected, along with acetone, in both blood and urine.

Evaluation and management of the critically ill adult with diabetic ketoacidosis

All relevant ethical issues were identified and discussed with the local Ethical Committee. All cases collected for this study underwent medico-legal autopsies as requested by the public prosecutor. Biochemical analyses were performed as part of the medico-legal investigations.

• The greatest threats to patients with alcoholic ketoacidosis are marked contraction in extracellular fluid volume (resulting in shock), hypokalaemia, hypoglycaemia, and acidosis.
• Conversely, albumin concentrations were not diminished and even increased in one case, which might also be related to the effect of hemoconcentration secondary to dehydration.
• Elevated serum amylase has been observed in about 50% of these patients.

BOX 3 MANAGEMENT OF AKA

However, if an AKA patient is lethargic or comatose, an alternative cause should be sought. They provide some energy to your cells, but too much may cause your blood to become too acidic. Finally, the WHO report highlights the fact that access to quality treatment for substanceuse disorders is still alcoholic ketoacidosis largely limited or unaffordable for those who need it most. “This affects almost half a billion of people worldwide who live with alcohol or drug use disorders,” notes Tedros in the report, pointing to “stigma, discrimination and misconceptions about the efficacy of treatment” as stubborn factors.

• This results in a decrease in circulating lactic acid and an increase in acetoacetate.
• There is increasing evidence that rather than being benign and self limiting, AKA may be a significant cause of mortality in patients with alcohol dependence.
• All cases were selected among the medico-legal autopsies performed in our center from 2011 to 2013.
• Different reference values have been proposed for acetone and beta-hydroxybutyrate in blood, vitreous, pericardial and cerebrospinal fluids to ascribe the cause of death to alcoholic ketoacidosis in the presence of other consistent data and exclusion of alternative causes of death.

Forensic Pathology

An altered level of consciousness should prompt consideration of alternative diagnoses such as hypoglycaemia, seizures, sepsis, thiamine deficiency, or head injury. Arterial blood gas and biochemistry studies reveal a raised anion gap metabolic acidosis without evidence of lactic or diabetic ketoacidosis. This case demonstrates the importance of considering AKA in the differential diagnosis of a patient presenting with non-specific symptoms, significant metabolic acidosis and a history of alcohol excess.

Alcoholic ketoacidosis: a cause of sudden death of chronic alcoholics

Clinical Bottom Line

Ethanol metabolism

Treatment / Management