Starvation-induced True Diabetic Euglycemic Ketoacidosis in Severe Depression

  • Franklin Joseph
  • Lydia Anderson
  • Niru Goenka
  • Jiten Vora
Case Reports/Clinical Vignettes


True euglycemic diabetic ketoacidosis [blood glucose <200 mg/dl (11.1 mmol/l)] is relatively uncommon and in type 1 diabetes can be caused by starvation of any cause in conjunction with an intercurrent illness. We report a case of euglycemic diabetic ketoacidosis precipitated by starvation resulting from severe depression in a patient with type 1 diabetes. He was acidotic with ketonuria, but his blood glucose was only 105 mg/dl (5.8 mmol/l). He was rehydrated, the acidosis was corrected, and his depression was later treated. This case involves the complex interplay among type 1 diabetes, depression, ketoacidosis, and starvation physiology resulting in glucose concentrations in keeping with euglycemic diabetic ketoacidosis. The case also highlights that even in the absence of hyperglycemia, acid/base status should be assessed in an ill patient with diabetes, and in cases of euglycemic diabetic ketoacidosis, the diagnosis of depression should be considered as a cause for suppressed appetite and anorexia.


type 1 diabetes depression ketoacidosis starvation 


Conflicts of Interest

None disclosed.


  1. 1.
    Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:2739–48.PubMedCrossRefGoogle Scholar
  2. 2.
    Munro JF, Campbell IW, McCuish AC, Duncan LJ. Euglycaemic diabetic ketoacidosis. Br Med J. 1973;2:578–80.PubMedGoogle Scholar
  3. 3.
    Jenkins D, Close CF, Krentz AJ, Nattrass M, Wright AD. Euglycaemic diabetic ketoacidosis: does it exist? Acta Diabetol. 1993;30:251–3.PubMedCrossRefGoogle Scholar
  4. 4.
    McNulty SJ, English PJ. Euglycaemic diabetic ketoacidosis. Practical Diabetes International. 2002;19:63.CrossRefGoogle Scholar
  5. 5.
    Davies RG, De P, Child DF, Gemmell L, Rincon C. Euglycaemic diabetic ketoacidosis. Hospital Medicine. 2003;64:557–8.PubMedGoogle Scholar
  6. 6.
    Burge MR, Garcia N, Qualls CR, Schade DS. Differential effects of fasting and dehydration in the pathogenesis of diabetic ketoacidosis. Metabolism. 2001;50:171–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Foster DW, McGarry JD. The metabolic derangements and treatment of diabetic ketoacidosis. N Engl J Med. 1983;309:159–69.PubMedGoogle Scholar
  8. 8.
    Burge MR, Hardy KJ, Schade DS. Short-term fasting is a mechanism for the development of euglycemic ketoacidosis during periods of insulin deficiency. J Clin Endocrinol Metab. 1993;76:1192–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Rothman DL, Magnusson I, Katz LD, Shulman RG, Shulman GI. Quantitation of hepatic glycogenolysis and gluconeogenesis in fasting humans with 13C NMR. Science. 1991;254:573–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Wolfe RR, Peters EJ, Klein S, Holland OB, Rosenblatt J, Gary H Jr. Effect of short-term fasting on lipolytic responsiveness in normal and obese human subjects. Am J Physiol. 1987;252:E189–96.PubMedGoogle Scholar
  11. 11.
    Jensen MD, Haymond MW, Gerich JE, Cryer PE, Miles JM. Lipolysis during fasting. Decreased suppression by insulin and increased stimulation by epinephrine. J Clin Invest. 1987;79:207–13.PubMedCrossRefGoogle Scholar
  12. 12.
    Owen OE, Licht JH, Sapir DG. Renal function and effects of partial rehydration during diabetic ketoacidosis. Diabetes. 1981;30:510–8.PubMedGoogle Scholar
  13. 13.
    Jenkins DW, Eckle RE, Craig JW. Alcoholic ketoacidosis. Jama. 1971;217:177–83.PubMedCrossRefGoogle Scholar
  14. 14.
    Tomihira M, Kawasaki E, Nakajima H, et al. Intermittent and recurrent hepatomegaly due to glycogen storage in a patient with type 1 diabetes: genetic analysis of the liver glycogen phosphorylase gene (PYGL). Diabetes Res Clin Pract. 2004;65:175–82.PubMedCrossRefGoogle Scholar
  15. 15.
    Clark JD, McConnell A, Hartog M. Normoglycaemic ketoacidosis in a woman with gestational diabetes. Diabet Med. 1991;8:388–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Franke B, Carr D, Hatem MH. A case of euglycaemic diabetic ketoacidosis in pregnancy. Diabet Med. 2001;18:858–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Metzger BE, Ravnikar V, Vileisis RA, Freinkel N. “Accelerated starvation” and the skipped breakfast in late normal pregnancy. Lancet. 1982;1:588–92.PubMedCrossRefGoogle Scholar
  18. 18.
    Brumfield CG, Huddleston JF. The management of diabetic ketoacidosis in pregnancy. Clin Obstet Gynecol. 1984;27:50–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Unger RH, Foster DW. Williams Textbook of Endocrinology. 9th edn. Philadelphia 1998.Google Scholar
  20. 20.
    Standards of medical care in diabetes – 2008: American Diabetes Association. Diabetes Care. 2008;31(Suppl 1):S12–54.Google Scholar
  21. 21.
    Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24:1069–78.PubMedCrossRefGoogle Scholar
  22. 22.
    Lustman PJ, Clouse RE, Carney RM. Depression and the reporting of diabetes symptoms. Int J Psychiatry Med. 1988;18:295–303.PubMedGoogle Scholar
  23. 23.
    Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23:934–42.PubMedCrossRefGoogle Scholar
  24. 24.
    Buchwald AM, Rudick-Davis D. The symptoms of major depression. J Abnorm Psychol. 1993;102:197–205.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Franklin Joseph
    • 1
  • Lydia Anderson
    • 1
  • Niru Goenka
    • 1
  • Jiten Vora
    • 2
  1. 1.Diabetes CentreCountess of Chester NHS Foundation TrustChesterUK
  2. 2.Department of Diabetes and EndocrinologyRoyal Liverpool University HospitalLiverpoolUK

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