A Rare Case of Elevated Osmolar Gap in Diabetic Ketoacidosis/Hyperosmolar Hyperglycaemic State in the Absence of Concomitant Toxic Alcohol Ingestion
  • Hardik Fichadiya
    Department of Internal Medicine, Rutgers NJMS/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Muhammad Atif Masood Noori
    Department of Internal Medicine, Rutgers NJMS/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Harshwardhan Khandait
    Department of Internal Medicine, Rutgers NJMS/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Latika Patel
    Department of Internal Medicine, Rutgers NJMS/Trinitas Regional Medical Center, Elizabeth, NJ, USA
  • Shruti Jesani
    Department of Internal Medicine, Rutgers NJMS/Trinitas Regional Medical Center, Elizabeth, NJ, USA

Keywords

Diabetic ketoacidosis, hyperglycaemic hyperosmolar state, osmolar gap, absence of toxic alcohol ingestion

Abstract

The serum osmolar gap, defined as the difference between measured osmolality and calculated osmolarity, is a convenient method to screen for toxins in serum. In normal circumstances, the difference between the two is 6–10 mol/kg. Typical contributors to serum osmolarity are sodium bicarbonate, sodium chloride, glucose and urea. An elevated gap, defined as a difference >10 mol/kg, can occur if a sufficient quantity of an additional solute other than those mentioned above is present in the serum or there are inaccuracies in sodium measurement secondary to hyperlipidaemia and hyperproteinaemia. An elevated serum osmolar gap should thus prompt clinicians to check for toxic alcohol levels. Treatment with fomepizole should not be delayed if suspicion is high. Isolated diabetic ketoacidosis can occasionally present with an elevated osmolar gap in the absence of concomitant alcohol ingestion. This finding is attributed to the production of acetone and glycerol. 
We describe the case of a 62-year-old man presenting with diabetic ketoacidosis/hyperosmolar hyperglycaemic state and an elevated osmolar gap in the absence of toxic alcohol ingestion.

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References

  • Misra S, Oliver NS. Diabetic ketoacidosis in adults. BMJ 2015;351:h5660. doi:10.1136/bmj.h5660
  • Stoner GD. Hyperosmolar hyperglycemic state. Am Fam Physician 2017;96(11):729–736.
  • Davidson DF. Excess osmolal gap in diabetic ketoacidosis explained. Clin Chem 1992;38(5):755–757.
  • Bhagat CI, Garcia-Webb P, Beilby JP, Hackett PL. Unexplained osmolal gap in diabetic ketoacidosis (not due to acetone). Clin Chem 1990;36(2):403–404.
  • Al-Darzi W, Chaaban S, Abu Sayf A, Tirgari S, Uduman J. Gaps in osmolal gap: a case of mistaken osmolal gap in a patient with diabetic ketoacidosis. Am J Respir Crit Care Med 2017;195:B57.
  • Zar T, Graeber C, Perazella MA. Recognition, treatment, and prevention of propylene glycol toxicity. Semin Dial 2007;20(3):217–219. doi:10.1111/j.1525-139X.2007.00280.x
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    Published: 2022-03-31
    Issue: 2022: Vol 9 No 3 (view)


    How to cite:
    1.
    Fichadiya H, Noori MAM, Khandait H, Patel L, Jesani S. A Rare Case of Elevated Osmolar Gap in Diabetic Ketoacidosis/Hyperosmolar Hyperglycaemic State in the Absence of Concomitant Toxic Alcohol Ingestion. EJCRIM 2022;9 doi:10.12890/2022_003248.

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