Category: Diabetes/Prediabetes/Hypoglycemia

Type: e-Poster

Monitor: 34

34 - A CASE OF DELAYED DIAGNOSIS OF DIABETIC KETOACIDOSIS PRESENTING WITH EUGLYCEMIA

Saturday, Apr 27
10:00 AM – 10:30 AM

Objective : To report a case of delayed diagnosis of ketoacidosis with SGLT-2 inhibitors that presented with euglycemia


Methods : n/a


Results : n/a


Discussion :

A 71-year old female presented with weakness and back pain starting after a minor motor vehicular accident two days prior. Her past medical history included Type 2 diabetes mellitus and cerebrovascular accident with residual right-sided weakness. Her medications included basal insulin, nateglinide, metformin, canagliflozin, and dulaglutide. She also had decreased appetite, nausea, vomiting and confusion per family. On exam, she was noted to be febrile up to 101.1 F, normotensive but tachycardic with pulse of 106 bpm and 94% saturation on room air. She appeared well with unremarkable cardiopulmonary exam. The patient’s initial laboratory results showed an elevated WBC of 19 K/uL and normal liver function test. The basic metabolic panel showed anion gap (AG) of 24 and blood glucose (BG) 312 mg/dL (17.3 mmol/L). Urinalysis had elevated glucose >1000, elevated ketones >100, & no bacteria. CT chest/abdomen/pelvis showed consolidation of the basal segments of the right lower lobe, concerning for post-obstructive pneumonia. The patient was admitted to Medicine and started on antibiotics for pneumonia with a plan for bronchoscopy for possible lung mass. On Day 3, bronchoscopy showed purulent secretions and vegetative lesions in the right lower lobe. Few hours after bronchoscopy, the patient developed altered mental status and shortness of breath with mild right upper extremity weakness. Code stroke was called and a stat CT head done was normal. Repeat blood work revealed still high anion gap metabolic acidosis with AG of 17, Glucose: 210 mg/dl (11.6 mmol/L). An arterial blood gas showed pH of 7.20 and beta- hydroxybutyrate was greatly elevated at > 4.0 mmol/L. Of note, patient’s point of care BG ranged from 149 to 235 mg/dL during her hospitalization. The patient was admitted to the ICU for euglycemic DKA attributed to canagliflozin. She was resuscitated with intravenous fluid and started on insulin infusion. Within 24 hours, her mental status improved.


Conclusion :

With the increasing popularity of SGLT2 inhibitors, this case illustrates the importance of recognizing how DKA can present atypically. The diagnosis can be challenging, especially without the significantly elevated blood glucose and the presence of other underlying diagnosis. On presentation, the patient had symptoms of DKA with an elevated anion gap and ketonuria. However, the diagnosis was delayed and only recognized when the patient acutely deteriorated. In patients who are taking an SGLT2 inhibitor, DKA should not be ruled out because of normal range glucose levels.

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Mariam R. Saand

Internal Medicine Resident
Englewood Hospital and Medical Center
Englewood, New Jersey

PGY2 internal medicine resident at Englewood Hospital and Medical Center, NJ. Originally from Pakistan. Interested in pursuing Endocrinology for fellowship.

Christina Jara

Internal Medicine Resident
Englewood Hospital and Medical Center

PGY3 resident at Englewood Hospital and Medical Center, NJ.

Mariam R. Saand

Internal Medicine Resident
Englewood Hospital and Medical Center
Englewood, New Jersey

PGY2 internal medicine resident at Englewood Hospital and Medical Center, NJ. Originally from Pakistan. Interested in pursuing Endocrinology for fellowship.

Huwad Choudhry