Diabetic Ketoacidosis Mimicking Respiratory Distress in an Obese Adolescent Patient: A Case Report

Abstract

Introduction: Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus characterized by hyperglycemia, ketosis, and metabolic acidosis requiring prompt management. In children and adolescents, DKA often represents the initial manifestation of diabetes and may mimic respiratory disorders, potentially leading to delayed diagnosis and increased morbidity.

Case Illustration: We report a case of a 13-year-old obese boy who presented to the emergency department with progressive shortness of breath for one week, accompanied by polyuria, polydipsia, nausea, fatigue, and significant weight loss of 5 kg. Physical examination revealed Kussmaul respiration and acanthosis nigricans on the neck. Laboratory findings demonstrated severe hyperglycemia (random blood glucose 381 mg/dL), marked ketonuria (+4), and severe metabolic acidosis with arterial pH 7.06 and bicarbonate 2 mEq/L, confirming severe DKA. The patient received comprehensive management according to ISPAD guidelines, including oxygen therapy, intravenous rehydration with calculated fluid replacement based on ideal body weight, and continuous intravenous insulin aspart infusion at 0.08 units/kg/hour. Blood glucose monitoring guided fluid adjustments with dextrose-containing solutions as glucose levels declined.

Discussion: The patient's respiratory manifestations, particularly Kussmaul respiration, represented physiological compensation for severe metabolic acidosis rather than primary pulmonary pathology. Obesity and acanthosis nigricans suggested underlying insulin resistance, potentially indicating type 2 diabetes mellitus, though definitive classification required further evaluation. Management followed ISPAD guidelines with gradual fluid correction over 48 hours to minimize cerebral edema risk, continuous insulin infusion until DKA resolution, and transition to subcutaneous basal-bolus insulin regimen. Clinical improvement was achieved by day four with pH increasing to 7.32 and bicarbonate to 18 mEq/L.

Conclusion: This case highlights the importance of recognizing DKA in adolescents presenting with respiratory symptoms, particularly in obese patients with insulin resistance markers. Prompt diagnosis and adherence to evidence-based protocols are essential for optimal outcomes and prevention of life-threatening complications.