Table 2. Previously published studies and case reports of MALA with demographics, initial presentation, diagnostic tests, findings, and management.

CBC: complete blood count; CMP: comprehensive metabolic panel; ABG: arterial blood gas; CPR: cardiopulmonary resuscitation; ECG: electrocardiogram; PEA: pulseless electrical arrest; ICU: intensive care unit; CKD: chronic kidney disease; ECMO: extracorporeal membrane oxygenation; LVEF: left ventricular ejection fraction; PO2: partial pressure of oxygen; PCO2: partial pressure of carbon dioxide; V-A ECMO: venoarterial extracorporeal membrane oxygenation

Study name	Demographics	Initial presentation	Diagnostic tests performed	Findings	Management/outcomes
Umeda et al. [11]	54-year-old Hispanic female	The patient presented with watery diarrhea, nausea, vomiting, and mental status changes	Blood glucose level, CBC, CMP, ABG, cardiac biomarkers, serial ECGs, echocardiogram, nuclear stress test, coronary angiography	Laboratory tests found a blood glucose level of 47 mg/dL, creatinine of 8.07 mg/dL, and elevated troponin of 4.42 ng/mL. ABG showed an arterial pH of 6.57 and bicarbonate of 2 mEq/L. Cardiac workup: Serial ECGs were negative for ST-T wave changes. Echocardiogram revealed a preserved ejection fraction of 50%. Nuclear stress test was abnormal. Coronary angiography revealed three vessel diseases with 80-90% stenosis	Management consisted of glucagon for hypoglycemia, CPR, endotracheal intubation, shock management, hemodialysis, and a coronary artery bypass graft. Outcome: The patient was discharged on day 15. Dialysis was discontinued in one month as renal function returned to baseline
Kinoshita et al. [12]	70-year-old Japanese female	The patient presented with diarrhea, nausea, and vomiting for three days with altered mental status	CBC, CMP, serum, metformin level, ABG	Laboratory tests found severe lactic acidosis with a pH of 6.618, bicarbonate of 1.7 mmol/L, lactate level of 18 mmol/L, severe acute kidney injury with BUN of 67.5 mg/dL and creatinine of 10.17 mg/dL, and metformin concentration of 77.5 mg/dL	Management consisted of intravenous fluids, sodium bicarbonate, antibiotics, vasopressors, endotracheal intubation, and continuous renal replacement therapy. Outcome: Discharged from hospital on day 20
Ncomanzi et al. [13]	66-year-old Caucasian female	The patient presented with a three-week history of generalized malaise, poor oral intake, and diarrhea	CBC, CMP, cardiac biomarkers, venous blood/gas measurement, serum metformin level	Labs showed sodium of 140 mmol/L, potassium of 7.3 mmol/L, bicarbonate of 1 mmol/L, BUN of 30.8 mmol/L, creatinine of 7.68 umol/L, anion gap of 55 mmol/L, troponin level of 50 ng/L, and metformin level of 4 mg/L. Venous blood gas measurements: profound metabolic acidemia: pH, 6.58; HCO3, 3.6 mmol/L; glucose, 2.0 mmol/L; and lactate, 16.7 mmol/L	Management consisted of endotracheal intubation and ventilation for PEA arrest, intravenous fluids, vasopressors, continuous renal replacement therapy, and intravenous antibiotics. Outcome: Discharged home on day 16 after a total 35-day stay in the ICU
Fadden et al. [4]	58-year-old female	The patient presented with diarrhea, vomiting, abdominal pain, and poor oral intake	CBC, CMP, lactate level, ABG	Labs showed a pH of 6.6, lactate level of 14 mmol/L, acute kidney injury, elevated WBC to 12.5×109/L on CBC, and glucose of 2.5 mmol/L. CT of the abdomen showed possible pancolitis	Management consisted of supportive treatment for brief systolic cardiac arrest, renal replacement therapy, and intravenous dextrose for severe hypoglycemia. Outcome: Discharged home on day 16
Shenoy [5]	48-year-old male	The patient presented with nausea, vomiting, diarrhea, abdominal pain, and lethargy	CBC, CMP, lactic acid level, ABG	Labs showed WBC of 33,000/mm3, bicarbonate of 7.0 mEq/L, creatinine level elevated to 2.9 mg/dL, BUN of 16 mg/dL, anion gap of 33, lactic acid level of 25.0 mmol/L, ABG with pH of 6.85, PCO2 of 17, and PO2 of 133 with an oxygen saturation of 95% on room air. The chest X-ray and ECG were normal	Management included intravenous fluids for viral gastroenteritis, bicarbonate drip, hemodialysis, intubation, and ventilator support for respiratory distress. Outcome: Discharged home five days after admission on rosiglitazone
Ashraf et al. [6]	53-year-old African American female	The patient presented with dizziness, generalized weakness, fatigue, and shortness of breath	CBC, CMP, ABG	Labs showed blood sugar of 34 mg/dL, hemoglobin A1c of 6.9%, CKD stage 3a with eGFR 8.51 mL/minute, creatinine of 6.6 mg/dL, potassium of 6.7 mmol/L, ABG with severe anion gap metabolic acidosis, and lactate of 20 mmol/L	Management with dextrose for hypoglycemia, broad-spectrum intravenous antibiotics, and dialysis. Outcome: Discharged back to the nursing home on day 8
Plumb et al. [14]	66-year-old female	The patient presented with a five-day history of diarrhea, vomiting, and abdominal pain	ABG, CBC, CMP, ECG, bedside echocardiogram	Labs showed a potassium of 7.4 mmol/L. ABG showed a pH of 6.57. ECG: No p waves, irregular broad complexes, and tall T waves consistent with hyperkalemia. The echocardiogram showed myocardial infarction	Management of pulseless electrical activity cardiac arrest with vasopressors and hemodialysis and methylene blue infusion. Outcome: Discharged home on day 18
White et al. [15]	52-year-old female	The patient presented with altered mental status, hypoglycemia, and shock	Prehospital ECG, metformin level	Labs showed a metformin concentration of 51 g/mL. ABG showed severe metabolic acidosis. The ECG showed findings of posterolateral ST-elevation myocardial infarction	Management consisted of emergent hemodialysis and treatment for acidosis and hypothermia. Outcome: Discharged from hospital
Chen et al. [16]	72-year-old female	The patient presented with nausea and fatigue	ECG, ABG, echocardiography	ABG showed a pH of 6.80, lactic acid of >15  mmol/L, and PCO2 of 14 mmHg. ECG: tachycardia with a wide QRS. Echocardiography showed a diffuse reduction of left ventricular wall motion, and the LVEF was 23.5%	Management included sodium bicarbonate drip, vasopressors, IVFs, dobutamine drip, V-A ECMO, and intubation with mechanical ventilation. Outcome: Discharged from the hospital on day 10
Hai et al. [17]	66-year-old male	The patient presented with fatigue, abdominal pain, nausea, vomiting, and severe diarrhea for three days	CBC, CMP, ABG	ABG showed pH of 6.94, PO2 of 151 mmHg, PCO2 of 14 mmHg, bicarbonate of 3 mmol/L, anion gap of 48 mmol/L, and lactate level of 15 mmol/L	Management included sodium bicarbonate and glucose control with insulin infusion, vasopressors, intravenous fluids, and continuous replacement therapy. Outcome: Discharged home on day 11