Pseudomyocardial Infarction in a Patient with Severe Diabetic Ketoacidosis and Mild Hyperkalemia

A 48-year-old male with a prior diagnosis of diabetes mellitus presented to the emergency department with malaise and nausea. On
work-up, he was found with hyperglycemia and high anion gap metabolic acidosis, with a blood pH < 6 94. A diagnosis of severe
diabetic ketoacidosis was established; serum electrolyte analysis showed mild hyperkalemia. On work-up, a 12-lead
electrocardiogram was obtained, and it showed an ST-segment elevation on anterior leads that completely resolved with diabetic
ketoacidosis treatment. ST-segment elevation myocardial infarction can be a precipitant factor for diabetic ketoacidosis, and
evaluation of diabetic patients with suspected myocardial infarction can be challenging since they can present with atypical or
little symptoms. Hyperkalemia, which usually accompanies diabetic ketoacidosis, can cause electrocardiographic alterations that
are well described, but ST-segment elevation is uncommon. A pseudomyocardial infarction pattern has been described in
patients with diabetic ketoacidosis; of note, most of these patients presented severe hyperkalemia. We believe this is of great
importance for clinicians because they must be able to recognize those patients that present with electrocardiographic
abnormalities secondary to the metabolic alterations and those that can be experiencing actual ongoing ischemia, in order to
establish an appropriate and prompt treatment.