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Misdiagnosis of diabetic ketoacidosis as hyperventilation syndrome.

1987; BMJ; Volume: 294; Issue: 6572 Linguagem: Inglês

10.1136/bmj.294.6572.630

0959-8138

R A R Treasure, P.B.S. Fowler, Hugh Millington, P. H. Wise,

Diabetes and associated disorders

Air hunger" is a classical symptom ofdiabetic ketoacidosis and was originally described by Kussmaul in 1874.1 We report three cases in which breathlessness and panic symptoms were the main presenting complaints in ketoacidosis.In all three cases an incorrect diagnosis of hyperventilation syndrome was made initially with a consequent and serious delay in the diagnosis ofdiabetes.So far as we know this is the first report of this diagnosiic error, which may be more 'frequent than is currently appreciated. Case reportsCase I-A 52 year old woman presented to the accident and emergency department with a three day history of panic attacks, palpitations, and breathlessness.In the past she had been treated for depression.Hysterical hyperventilation was diagnosed and diazepam prescribed and she was referred to a psychiatrist.Three days later she returned.In addition to her original symptoms she complained of weight loss, polyuria, and dysuria.Laboratory investigations showed a blood glucose concentration of 32-6 mmol/l and an arterial pH of 7-2.She was treated for diabetic ketoacidosis and recovered uneventfully.She continued with insulin injections and had no further "panic attacks."Case 2-A 24 year old woman attended the accident and emergency department complaining of breathlessness, faintness, and weight loss.She' had recently been suffering from depression and had attended another hospital the previous day, where she had been referred to a psychiatrist.On this occasion hysterical hyperventilation was diagnosed.She was made to rebreathe exhaled air and given an outpatient psychiatric appointment.Two days later she returned.She was semiconscious, dehydrated, and hypo- tensive.Laboratory investigations showed a blood glucose concentration of 58 mmol/l and an arterial pH of 6-99.Diabetic ketoacidosis was diagnosed and appropriate treatment instituted.She recovered and left hospital taking insulin.She remained well.Case 3-A 34 year old woman presented complaining of an infected leg wound and breathlessness.The diagnosis was an infected catbite and hysterical hyperventilation and she was prescribed diazepam and antibiotics.Two days later she was brought to the department unconscious.An infected wound to the right thigh was noted and she was hypotensive and hypothermic.Results of laboratory investigations were: blood glucose concentration 45 mmol/l, arterial pH 6-75, serum sodium concentration 128 mmol/l, blood urea concentration 27 2 mmol/l, and potassium concentration 6-8 mmol/l.A diagnosis of diabetic ketoacidosis with possible septicaemia and a groin abscess was made.She was treated with intravenous fluids, insulin, and antibiotics and the abscess drained.Dialysis was required for three days for acute renal failure.She recovered and remained well taking insulin injections.