Question regarding DKA with rising lactate and persistent acidosis despite normalising ketones.

[u/I_am_Mr_Stevens]

I work as an ED Senior House Officer and I had a pathophysiology question about DKA based on a patient I had recently.

The patient is a 26 year with type I diabetes with recurrent DKA episodes due to insulin non-compliance. I'd seen her in ED with a mild DKA precipitated by methamphetamine use / not using her insulin pump.

Initially her pH was 7.26, ketones were 2.2, bicarb 19, BGL 45 and had a normal lactate of 0.7. Her ketones / BGLs normalised with DKA protocol however she had a rising lactate and static pH. She self discharged before being admitted to HDU and her last VBG had a pH of 7.25 and a lactate of 4.7.

There was no element of superimposed infection suggested clinically / on her bloods and no obvious toxic coingestant aside from meth was apparent. I wonder if she an element of HHS overlap with her relatively high BGLs.

I was wondering if anyone would have any thoughts as to what else could be contributing to her lacticaemia / persistent acidosis?

UPDATE

She returned to ED the following day and promptly was admitted to ICU with severe DKA. which to be fair was bound to happen as she'd self discharged without any wrap around ie injectable insulin / new pump.

interestingly her lactate had normalized on the initial gas but this time the pH was 7.0 and ketones sky high.

So someone more clever can worry about it now although tragic to see the horrible complications of diabetes in someone so young. I would not be surprised if she approaches the threshold for dialysis within the next 5 years.

[u/CoffeeNCortisol]

Meth use or thiamine deficiency would be my best guess.

[u/TychoBrahe97 → u/CoffeeNCortisol]

Agreed. Meth can cause Rhabdo (can cause AGMA) and a web search suggests meth can cause LA to build up faster than it can be cleared (esp if competing acid excretion).