Case Presentation: A 48-year-old male nurse presented with one week of fever, nausea, abdominal pain, dysuria, urinary frequency, and suprapubic pain. His past medical history was significant for type 2 diabetes mellitus (recent hemoglobin a1c 7.6%) without complication, on metformin and the SGLT-2 inhibitor canagliflozin. His physical exam was notable for fever to 39.2 C, sinus tachycardia to 140, bilateral costovertebral angle tenderness, and a non-tender prostate exam. His labs were pertinent for a leukocytosis of18.8, bicarbonate of 14, anion gap of 23, creatinine of 1.4 from a baseline of 0.8, and glucose of 165. His urinalysis showed >1000 glucose, 20-100 WBC, and trace ketones. Initial presentation was consistent with pyelonephritis with acute kidney injury, and he was started on ceftriaxone. However, the large anion gap led to further work up revealing a metabolic acidosis with pH 7.3 on arterial blood gas and massive ketonemia with a beta hydroxybutyrate of 40. With an additional diagnosis of euglycemic diabetic ketoacidosis, he was started on dextrose enhanced intravenous fluids and an insulin drip. His urine culture eventually grew out multidrug resistant E Coli and his symptoms resolved on above therapies.
Discussion: Euglycemic diabetic ketoacidosis (DKA) can present subtly and is a significant diagnostic challenge in the hospital setting. Because diabetic patients often present with infection and concomitant sepsis or acute kidney injury can mask the anion gap metabolic acidosis of DKA, patients’ ketonemia may be missed and left untreated. Furthermore, patients on SGLT-2 inhibitors often fail to exhibit the traditionally marked hyperglycemia that prompts hospitalists to screen for DKA. An increasing number of patients are taking SGLT-2 inhibitors now that they are second line agents for treatment of type 2 diabetes in the 2017 ADA guidelines. Euglycemic DKA should be suspected in any patient taking SGLT-2 inhibitors with high anion gap metabolic acidosis even in the presence of euglycemia. While not defined explicitly, SGLT-2 inhibitor use, ketonemia, and anion gap metabolic acidosis even in the presence of euglycemia is diagnostic of euglycemic DKA. Recognition of an anion gap elevation that would not be expected for pyelonephritis alone led to discovery of our patient’s severe ketonemia. Management included aggressive fluid resuscitation with dextrose enhanced fluid and an insulin drip. Other side effects of SGLT-2 inhibitors include urinary tract infections due to its glucosuric effect which was thought to be the etiology of his pyelonephritis.
Conclusions: Hospitalists should have a high index of suspicion for euglycemic DKA in patients on SGLT-2 inhibitors presenting with infections, as sepsis or acute kidney injury may mask the portion of the anion gap elevation that is due to ketonemia and pronounced hyperglycemia is often not present.
To cite this abstract:Sit, A; Yu, R. Sour without the Sweet: A Subtle Presentation of Euglycemic Diabetic Ketoacidosis. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 860. https://www.shmabstracts.com/abstract/sour-without-the-sweet-a-subtle-presentation-of-euglycemic-diabetic-ketoacidosis/. Accessed March 31, 2020.