Metabolic Acidosis in Chronic Alcoholism: When It’s Not Just Diabetic Ketoacidosis

Metabolic acidosis with ketosis is a medical emergency. Due to divergent management strategies, prompt differentiation is required between diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and euglycemic diabetic ketoacidosis (euDKA). We present the case of a 28-year-old woman with heavy alcohol use who presented with severe metabolic acidosis, ketosis, and hyperglycemia who was initially treated for DKA. Unexpected lab discrepancies in the course of treatment including hypoglycemia despite dextrose infusion raised suspicion for AKA. Elevated C-peptide, normal HbA1c, and absent anti-islet antibodies confirmed the diagnosis. This case underscores the importance of recognizing AKA's distinct pathophysiology and avoiding inappropriate insulin therapy. A systematic approach to metabolic acidosis with ketosis, emphasizing clinical context and lab correlation, is critical to prevent mismanagement.