Alcoholics may develop ketoacidosis as a consequence of high ethanol intake and poor diet. The presence of elevated beta-hydroxybutyric acid (BHBA) can help identify alcoholic ketoacidosis and can help establish the cause of death in deceased alcoholics.


Alcoholics may have a diet rich in ethanol but with little other nourishment. This results in glycogen depletion and lipolysis, with release of free fatty acids (see section above on metabolic markers of ethanol use). The release of free fatty acids increases production of ketone bodies with increased levels of acetoacetic acid, acetone and BHBA. The biochemical pathways involved are shown in Figures 1-3 (pages 623-626).


Findings in fatal cases of alcoholic ketoacidosis:

(1) unexpected death in a chronic alcoholic

(2) no or trace alcohol levels in the blood

(3) increased blood acetone levels

(4) no other cause of death identified at autopsy (gross, microscopic, culture, toxicology)

Blood Levels of BHBA


< 500 µmol/L


500 – 2,500 µmol/L


> 2,500 µmol/L

potentially lethal without medical attention


Differential diagnosis: diabetic ketoacidosis


According to the Merck Index, the molecular weight of beta-hydroxybutyric acid is 104.11 grams. The conversion for mg to µmoles is 9.605 in Tietz. The formula weight in the Sigma catalogue is 126.1 grams, but this is for the sodium salt.


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