Severe diabetic ketoacidosis in combination with starvation and anorexia nervosa at onset of type 1 diabetes: a case report

Abstract

We here report a case of diabetic ketoacidosis at onset of type 1 diabetes after a prolonged period of starvation due to anorexia nervosa. A 53-year-old female with a history of anorexia nervosa was admitted to the psychiatric clinic due to psychotic behaviour and inability to take care of herself. Twenty-four hours after admission she was transferred to the clinic of internal medicine due to altered mental status, and laboratory screening revealed a pH of 6.895 and blood glucose concentration of 40 mmol/L. Due to the unusual combination of prolonged starvation and diabetic ketoacidosis we implemented some modifications of existing treatment guidelines and some special considerations regarding nutrition in order to prevent a re-feeding syndrome.

Figure 1.

Plot of pH, plasma glucose concentration, and arterial gas values during the first 24 hours of care at the ICU. Bicarbonate was administered i.v. during the first hour, and the insulin infusion was initiated six hours after admission to the ICU. A: pH value, normalized (7.35) after 15 hours. B: Glucose concentration (mmol/L) continuously decreased up until 15 hours after admission when glucose infusion was initiated. C: Arterial CO₂ displayed extremely low values, <1 kPa. After 11 hours there was an increase which correlated to an increased pH level. CO₂ was not normalized until 30 hours after admission. D: Arterial O₂ continuously decreased and reached normal levels (12.6 kPa) after 25 hours.