Severe hypertriglyceridemia causing pseudo-acidosis: a case report

Abstract Background: Pseudo hypobicarbonatemia is a rare phenomenon associated with spuriously low bicarbonate levels in the presence of elevated triglycerides (TG). TG's interfere with commonly used enzymatic assays in BMP, giving falsely low bicarbonate levels. It adds to the diagnostic dilemma and possible extensive workup to identify the cause. Previous case reports have used plasmapheresis in these settings. We report the successful use of insulin infusion in managing a case of pseudo-acidosis secondary to severely high TG levels. Case presentation: Our patient was a 53-year-old female who presented with complaints of progressive fatigue. Her bicarbonate was 5 mmol/L on workup, anion gap was 30 mmol/L, with elevated TG levels. (5904 mg/dL). Arterial blood gas analysis showed normal pH (7.32) and normal calculated bicarbonate. (22.8mEq/L) Insulin infusion was started along with adding fenofibrate and atorvastatin. TG levels decreased progressively to 509 mg/dL with an associated normalization of bicarbonate levels and anion-gap acidosis on BMP. The patient was discharged on day 8 of her hospital stay. Conclusion: Hyper TG can lead to pseudo hypobicarbonatemia, presenting as pseudo anion gap metabolic acidosis. It is essential to correlate the lab findings in the perspective of clinical findings to avoid over-testing and clinical misdiagnosis. In addition, these patients can be managed safely with insulin infusion in resource-limited settings.