Clinical and laboratory findings led us to an initial diagnosis of
DKA. However, no improvement in encephalopathy occurred in
spite of intravenous fluids and insulin therapy. These findings, in
combination with the pancytopenia, the history of a first-degree
cousins marriage between parents, the family history of sudden
deaths of unknown cause and the sweaty feet odor, pointed
towards an inborn error of metabolism. Detection of typical
metabolites in blood and urine and mutation screening analyses
confirmed the diagnosis of IVA (Figure 1). The pathophysiology of
hyperglycemia in IVA has not yet been identified. We hypothesize