SHM Converge Scientific Abstract ePoster Gallery-Not So Sweet: A Case of Missed Euglycemic Diabetic Ketoacidosis

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A 60-year-old woman with small cell carcinoma of the sinuses, type 2 diabetes on an insulin pump plus empagliflozin, and a recent pulmonary embolus on apixaban was admitted for intractable nausea, vomiting, and tachycardia after chemotherapy. She had poor oral intake, shortness of breath, and heart rates around 130 at home. Initial vitals showed tachycardia without fever or hypotension. Labs revealed an anion gap metabolic acidosis with bicarbonate 15 mmol/L, anion gap 21, normal glucose at 140 mg/dL, normal lactate, and ketonuria.<br /><br />Her symptoms were initially attributed to chemotherapy side effects, dehydration, and starvation ketosis. On hospital day 2, symptoms persisted and cardiopulmonary workup, including CT angiogram and echocardiogram, was normal. By day 3, she worsened with heart rates in the 150s and more severe acidosis (bicarbonate 10 mmol/L) with markedly elevated beta-hydroxybutyrate (15 mmol/L) despite glucose of 137 mg/dL. She was transferred to the ICU and started on an insulin drip. By day 4, her nausea, vomiting, tachycardia, and acidosis improved after her insulin requirements increased substantially.<br /><br />This case highlights euglycemic diabetic ketoacidosis (DKA), a potentially missed diagnosis in patients taking SGLT2 inhibitors such as empagliflozin. SGLT2 inhibitors increase DKA risk, especially when combined with insulin, because insulin doses may be lowered too much, leading to lipolysis and ketone production, while the drugs also reduce renal ketone clearance. Risk is increased with poor oral intake, pregnancy, and insulin use before hospitalization.<br /><br />The key lesson is that any diabetic patient on an SGLT2 inhibitor who presents with nausea, vomiting, malaise, or acidosis should be evaluated for DKA with serum ketones, even if the blood glucose is normal.

Asset Subtitle

Mark Sonderman

Meta Tag

Author List Mark Sonderman

Category Clinical Vignettes

Concept Euglycemic Diabetic Ketoacidosis

Concept SGLT-2 Inhibitors

Concept Metabolic Acidosis

Concept Ketosis

Concept Blood Glucose

Distinguished Non-Finalist

Presenter Organization Vanderbilt University Medical Center

Presenting Author Mark Sonderman

Track Adult

Keywords

euglycemic diabetic ketoacidosis

SGLT2 inhibitor

empagliflozin

type 2 diabetes

insulin pump

anion gap metabolic acidosis

ketonuria

beta-hydroxybutyrate

nausea and vomiting

chemotherapy

Euglycemic Diabetic Ketoacidosis

SGLT-2 Inhibitors

Metabolic Acidosis

Ketosis

Blood Glucose