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Dear Sirs

Rosival describes our explanation of the case as ‘very improbable’ and implies that our patient may have had hyperglycaemic hyperosmolar syndrome without ketoacidosis ( HONK).[1] HONK occurs in Type 2 diabetic patients, with residual insulin secretion; however, we demonstrated (by glucagon-stimulated c-peptide measurement) that our patient had Type 1 diabetes i.e. insulin deficiency.[2]
We agree adrenal hormones are typically elevated in diabetic metabolic decompensation
(HONK and ketoacidosis) and are indeed implicated in the pathogenesis of both. Our
case illustrated this point: despite the fact that our patient had proven absolute insulin
deficiency (the hallmark of Type 1 diabetes), she did not develop ketoacidosis because
of her co-existent glucocorticoid deficiency (Addison’s disease).

Yours sincerely

Dr S J McNulty
Dr K J Hardy

References

(1) Rosival V. Failure to develop diabetic ketoacidosis in a newly presenting type 1 diabetic patient.
Postgrad Med J 2002;78:919, 317. [Full Text

(2) McNulty SJ, Hardy KJ. Failure to develop diabetic ketoacidosis in a newly presenting type 1 diabetic patient.
Postgrad Med J 2001;77:913,734. [Full Text]

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