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IMMINENT CATASTROPHE: GP can avoid (EPOSTER: 4mins)

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Background: Fasting has been a well-known modality for weight loss since olden times but its efficiency and safety profile has not yet been established. The metabolic effects can be deleterious if unnoticed. 
 
Case report: A 56 years old gentleman with past h/o Gout, on allopurinol, on light alcohol intake, came for checking insulin resistance. On further questioning, he came with h/o fasting for last 15 days and was sustaining himself on black coffee, green tea and electrolytes. He claimed to have lost 13 kilos since then but was feeling fine. His vitals were stable and systemic examination was normal. He was explained the risk of metabolic complications of prolonged fasting viz hypoglycaemia, dyselectrolemia, ketoacidosis and multiorgan failure. Patient was firm for his diet but got willing for routine bloods in addition to insulin resistance. He was explained the red flags. His bloods were deranged, UEC: low bicarb: 20 (normal 22-32 mmol/L), high Uric acid: 0.88 (normal: 0.21-0.43 mmol/L), high anion gap: 25 (9-19mmol/L), high creatinine: 130 (normal: 60-110micromol/L), rest was normal including FBC, LFT, BSL, insulin, HbA1C. Patient denied going to ED despite being advised and he wanted to achieve acidosis only for improving his insulin resistance. Repeat tests next day revealed that anion gap increased to 28, bicarb reduced to 19, urine glucose: nil, urine ketone: 3+, venous blood gas: pH: 7.26 (normal: 7.31-7.41), HCO3: 16 (23-29mmol/L), pO2, pCo2: normal range. There was no dyselectrolemia or hypoglycaemia. He was advised for ED for urgent medical attention, observation and hydration. He started eating normally before leaving for hospital and thus kept for few hours for observation in ED and discharged afterwards. He was followed up later, bloods was normal. This was a case of asymptomatic euglycemic starvation induced ketoacidosis which could have led to catastrophe if not picked up on time. Conclusions: Given the present day popularity of fasting, health care providers should be aware of euglycemic metabolic acidosis as a possible complication. A good patient doctor relationship can avoid potential danger in asymptomatic settings. 
 
References: Joanna C Blanco , Akshay Khatri , Alina Kifayat , Ronald Cho , Wilbert S Aronow Am J Case Rep 2019 Nov 22;20:1728-1731 Swapna Chalasani , Jacqueline Fischer J Med Case Rep2008 Feb 11;2:45. AliceLarroumeta MarionCamoin aNinonFoussarda LaureAlexandre.aLaurenceBaillet-Blanco.a VincentRigalleau., aKamelMohammedi., aNutrition, Volume 72, April 2020, 110668

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