Starvation Ketoacidosis Induced by Ketogenic Diet and Consumption of Ketone Supplement.

The ever-changing landscape of dieting and its correlation with health outcomes have continued to evolve with time. New diets appear and disappear just as quickly as they gain notoriety. This is a rare case of a 67-year-old female with a history of type II diabetes who presented with generalized weakness, nausea, and vomiting, and was found to have severe anion gap metabolic acidosis. In an effort to lose weight, she was combining a ketogenic diet with prolonged fasting and exogenous ketone supplement use that she purchased online. The patient reported drinking an exogenous ketone ester supplement that contained 30 g of D-beta hydroxybutyrate (BHB) per serving, three times per day. This case is unique in that the patient was initially thought to be in diabetic ketoacidosis upon arrival, but after further investigation into her initial labs, medication, and social history, the underlying factor for hospitalization became evident; that is, a combination of a ketogenic diet with prolonged fasting and exogenous BHB-induced ketoacidosis in the setting of type II diabetes. Thus, this case highlights the importance of thorough history taking, the dangers of over-the-counter supplement consumption, and the risks consumers inherit with trend dieting.

An atypical complicated left-sided bronchopleural fistula presenting more than seven months after lobectomy.

BACKGROUND: Bronchopleural fistulas (BPF) are abnormal sinus tracts connecting the bronchi and pleural cavity and form after surgical resection of a lung lobe. It is a complication with potentially disastrous sequelae including, failure of the bronchial stump to heal, ischemia of the affected area, and/or infection of the stump. Bronchopleural fistulas caused by surgical intervention most commonly present on the right side and within 7-12 days post-operatively, i.e., subacutely. While the fistula may initially be asymptomatic, they carry a mortality rate of 25-71% in the absence of other comorbidities. CASE PRESENTATION: A 60-year-old female developed a BPF more than seven months after a left lower lobe lung lobectomy for non-small cell adenocarcinoma is presented. She was seen at our hospital on multiple occasions after her lobectomy with no evidence of a developing fistula on chest computer tomography (CT) during those visits. During her most recent presentation, roughly 7 months postoperatively, she was noted on imaging to have a new left-sided bronchopleural fistula. Bronchoscopy with lavage and culture of the fistula grew Pseudomonas Aeruginosa, for which she received appropriate treatment. Further surgical interventions were deferred due to poor prognosis. Her presentation differed from the typical BPF presentation in that it was left-sided and occurred out of the window of its usual occurrence. CONCLUSION: Late-onset BPF is an important diagnosis to consider in patients who have undergone lung resection, regardless of the type of surgery or postoperative duration, especially when patients are known to have multiple predisposing factors.