PT - JOURNAL ARTICLE AU - Jojanneke Epke van Amesfoort AU - Dominique E Werter AU - Rebecca C Painter AU - Frederik J R Hermans TI - Severe metabolic ketoacidosis as a primary manifestation of SARS-CoV-2 infection in non-diabetic pregnancy AID - 10.1136/bcr-2021-241745 DP - 2021 Apr 01 TA - BMJ Case Reports PG - e241745 VI - 14 IP - 4 4099 - http://casereports.bmj.com/content/14/4/e241745.short 4100 - http://casereports.bmj.com/content/14/4/e241745.full SO - BMJ Case Reports2021 Apr 01; 14 AB - We present a case of a metabolic acidosis in a term-pregnant woman with SARS-CoV-2 infection.Our patient presented with dyspnoea, tachypnoea, thoracic pain and a 2-day history of vomiting, initially attributed to COVID-19 pneumonia. Differential diagnosis was expanded when arterial blood gas showed a high anion gap metabolic non-lactate acidosis without hypoxaemia. Most likely, the hypermetabolic state of pregnancy, in combination with maternal starvation and increased metabolic demand due to infection, had resulted in metabolic ketoacidosis. Despite supportive treatment and rapid induction of labour, maternal deterioration and fetal distress during labour necessitated an emergency caesarean section. The patient delivered a healthy neonate. Postpartum, after initial improvement in metabolic acidosis, viral and bacterial pneumonia with subsequent significant respiratory compromise were successfully managed with oxygen supplementation and corticosteroids. This case illustrates how the metabolic demands of pregnancy can result in an uncommon presentation of COVID-19.