No ingestion, no inhalation, still toxic: acetone poisoning via skin absorption.

This case demonstrates two concurrent mechanisms: starvation ketoacidosis as the primary driver of anion-gap acidosis and transdermal isopropyl alcohol exposure with hepatic conversion to acetone as a plausible contributor to acetonemia and the elevated osmolar gap.

Clinicians should consider noningestional exposures in unexplained dual-gap acidosis, especially in patients with neurodisability and device-adjacent or compromised skin. CLINICAL TRIAL NUMBER: Not applicable.