{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T00:15:16Z","timestamp":1758845716226,"version":"3.44.0"},"reference-count":11,"publisher":"BMJ","issue":"9","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,9,6]]},"published-print":{"date-parts":[[2025,9]]},"abstract":"<jats:p>Starvation-induced non-diabetic ketoacidosis (NDKA) is a typically mild condition. Here, we report life-threatening NDKA induced by a brief period of starvation in a patient with undiagnosed hyperthyroidism. A Japanese woman in her mid-30s, with intellectual disabilities and selective mutism, presented with a 3\u2009day history of vomiting and anorexia. She developed severe high-anion-gap metabolic acidosis, marked by elevated serum ketone bodies and normal blood glucose levels. Furthermore, mild-to-moderate hyperthyroidism was detected, which was later diagnosed as Graves\u2019 disease. The patient required intensive care, including a single session of haemodialysis, intravenous glucose-containing fluids, antithyroid medication and continuous intravenous beta-blocker infusion. These interventions led to acidosis resolution and normalisation of thyroid function. This case highlights that coexisting hyperthyroidism, even if mild to moderate, could dramatically exacerbate starvation-induced NDKA. Clinicians should consider hyperthyroidism in patients presenting with severe ketoacidosis.<\/jats:p>","DOI":"10.1136\/bcr-2025-266337","type":"journal-article","created":{"date-parts":[[2025,9,25]],"date-time":"2025-09-25T10:30:22Z","timestamp":1758796222000},"page":"e266337","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Severe non-diabetic ketoacidosis due to starvation and Graves\u2019 disease"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-5025-2916","authenticated-orcid":false,"given":"Koki","family":"Yamamoto","sequence":"first","affiliation":[{"name":"Department of General Internal Medicine, Seirei Hamamatsu General Hospital Epilepsy Center, Hamamatsu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6805-8108","authenticated-orcid":false,"given":"Yuki","family":"Honda","sequence":"additional","affiliation":[{"name":"Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Japan"},{"name":"Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kazuhito","family":"Saito","sequence":"additional","affiliation":[{"name":"Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,9,25]]},"reference":[{"key":"2025092503300912000_18.9.e266337.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ccc.2012.07.001"},{"key":"2025092503300912000_18.9.e266337.2","doi-asserted-by":"publisher","DOI":"10.1172\/JCI1089"},{"key":"2025092503300912000_18.9.e266337.3","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000028253","article-title":"Non-diabetic ketoacidosis secondary to primary hyperthyroidism: A case report","volume":"101","author":"Al-Mashdali","year":"2022","journal-title":"Medicine (Baltimore)"},{"key":"2025092503300912000_18.9.e266337.4","doi-asserted-by":"publisher","DOI":"10.1089\/1050725041692945"},{"key":"2025092503300912000_18.9.e266337.5","doi-asserted-by":"crossref","DOI":"10.1002\/ccr3.9698","article-title":"Hyperthyroidism-Induced Nondiabetic Ketoacidosis: A Rare Case Report","volume":"13","author":"Battikh","year":"2025","journal-title":"Clin Case Rep"},{"key":"2025092503300912000_18.9.e266337.6","unstructured":"Jeng HS , Michelle K , Figen U . Thyrotoxicosis presenting with nondiabetic ketoacidosis in a 4 year old female: a case report posters. 2019.121. Available: https:\/\/scholarlyexchange.childrensmercy.org\/posters\/"},{"key":"2025092503300912000_18.9.e266337.7","doi-asserted-by":"publisher","DOI":"10.2337\/dci24-0032"},{"key":"2025092503300912000_18.9.e266337.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejogrb.2012.10.005"},{"key":"2025092503300912000_18.9.e266337.9","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1111\/j.0954-6820.1979.tb00717.x","article-title":"Development of ketonemia in fasting patients with hyperthyroidism","volume":"624","author":"Bartels","year":"1979","journal-title":"Acta Med Scand Suppl"},{"key":"2025092503300912000_18.9.e266337.10","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1007\/s11892-020-01307-x","article-title":"Euglycemic Ketoacidosis","volume":"20","author":"Bonora","year":"2020","journal-title":"Curr Diab Rep"},{"key":"2025092503300912000_18.9.e266337.11","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1407778"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2025-266337","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,25]],"date-time":"2025-09-25T10:30:25Z","timestamp":1758796225000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2025-266337"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9]]},"references-count":11,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9,25]]},"published-print":{"date-parts":[[2025,9]]}},"alternative-id":["10.1136\/bcr-2025-266337"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2025-266337","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9]]}}}