To the Editor.—
The article by Schade and Eaton (241:2064, 1979) on the differential diagnosis and therapy for the hyperketonemic state1 may have the unintended effect of lulling the reader into ignoring perhaps less common but equally serious and lethal causes of hyperketonemia and ketonuria.Isopropyl alcohol intoxication is associated with hyperketonemia and ketonuria1 without glycosuria or acidosis. The experience of Ashkar and Miller2 and Vermeulen3 warns us that unraveling the cause of hyperketonemia in a diabetic alcoholic with access to isopropyl alcohol can be confusing and difficult. Also, mildly elevated serum ketone levels were reported in a case of cyanide poisoning.4The isopropyl alcohol intoxication would probably represent a fifth category of hyperketonemic causes. It is purely exogenous. The hyperketonemia of cyanide poisoning is neither well established nor clear in etiology, but may relate to severe lactic acidosis and stress.