Diabetic Ketoacidosis and Sepsis: A Diagnostic Challenge

Diabetic ketoacidosis is the most common complication of diabetes mellitus; infection can be a precipitating factor in almost 50% of cases. Description of the Case Report: A 74-year-old woman with type 2 diabetes was admitted at our emergency department for an alteration of consciousness, afebrile, abdominal rush with an eschar and a vesicular rash extended to the entire left arm. The patient had severe metabolic acidosis with glucose of 720 mg/ dL and hyperlactatemia. Restoration of intravascular volume and correction of electrolyte abnormalities, acidosis and hyperglycemia were carried out. After 20 minutes she had a worsening of the consciousness state (GCS 8). A non-contrast head CT was negative for acute hemorrhagic or ischemic changes, and an EEG was free of clear epileptiform abnormalities. Neck examination showed rigidity in flexion and doubtful meningeal signs. Due to the high index of suspicion, lumbar puncture was performed that revealed clear cerebrospinal fluid (CSF), hyperglycorrhachia, proteinorrhachia, pleocytosis. Empirically, patient was started with Acyclovir. CSF -PCR was positive to the Varicella Zoster Virus, leading to the diagnosis of Herpetic Encephalitis. Conclusions: Encephalitis can occur without fever. Alteration of consciousness, common to both diabetic ketoacidosis and encephalitis, can be a confounding factor for a correct diagnos