Normoglycemic High Anion Gap Metabolic Acidosis With Hyperkalemia: An Unusual Presentation of Alcoholic Ketoacidosis

Alcoholic ketoacidosis (AKA) is a form of high anion gap metabolic acidosis characterized by ketosis, typically occurring in malnourished individuals after binge alcohol consumption. If not identified early, it can lead to life-threatening electrolyte disturbances and cardiac arrhythmias. A man in his fifties presented with altered mental status and shortness of breath. Arterial blood gas analysis revealed severe metabolic acidosis with a pH of 7.22, a bicarbonate level of 4.2 mmol/L, and normal lactate levels. Urine ketones were strongly positive (4+). Electrocardiography demonstrated tall T waves, and serum potassium was elevated at 5.8 mEq/L. The combination of recent binge alcohol use, normoglycemia, ketosis, and high anion gap metabolic acidosis suggested AKA. Prompt fluid resuscitation and electrolyte correction resulted in progressive clinical improvement, and the patient was discharged without complications. This case highlights the importance of considering AKA in normoglycemic patients presenting with high anion gap metabolic acidosis and ketosis, particularly those with a history of excessive alcohol consumption. Accurate differentiation from diabetic ketoacidosis is essential because management strategies differ significantly. It is further distinguished by significant hyperkalemia with electrocardiographic changes, an atypical presentation of AKA in which serum potassium levels are usually normal or low.