Don’t Forget Ketoacidosis
That the article (1) focuses on the differentiation of pulmonary and cardiac causes is understandable, due to their frequency. However, it thereby neglects metabolic causes, although these are by no means rare and are of high practical relevance.
I have repeatedly seen type 1 diabetes in children and youth lead to ketoacidosis that is misdiagnosed as pulmonary dyspnea. The snag for two young patients was that both had known pulmonary problems: a small child with recurrent obstructive bronchitis, and a youth with bronchial asthma. Neither child was known to have diabetes, which manifested itself acutely with severe metabolic imbalance. During the very full office visitation hours (“infection season”), each was treated with inhalation or with cortisone after a short consultation with the attending physician (pneumologist or pediatrician). The subsequent medical examination likewise did not lead to the correct diagnosis, giving them a rocky start.
Both came to the clinic with severe acidosis in extremis (with pH values of 6.8 and 6.9!), but thankfully, both survived without complications. A diabetic ketoacidosis must be taken into consideration for dyspnea at every age, especially in light of the ever increasing incidence of type 1 diabetes mellitus. Also, the respiratory sounds should be differentiated—breathing during an asthma attack or a psychogenic hyperventilation differs markedly from the deep breathing in metabolic acidosis (“kussmaul”).
In general, it is important to keep in mind that any anamnesis should be adequately addressed with open questions before attempting to differentiate into more precise specifications. It is often the case that a broader anamnesis would have given decisive indications to avoid a misdiagnosis, such as the symptoms mentioned above that are typical for diabetes.
Prof. Dr. med. Walter Burger
|1.||Berliner D, Schneider N, Welte T, Bauersachs J: The differential diagnosis of dyspnoea. Dtsch Arztebl Int 2016; 113: 834–45. VOLLTEXT|