PMID- 35573514
OWN - NLM
STAT- PubMed-not-MEDLINE
LR  - 20220716
IS  - 2168-8184 (Print)
IS  - 2168-8184 (Electronic)
IS  - 2168-8184 (Linking)
VI  - 14
IP  - 4
DP  - 2022 Apr
TI  - An Unsuspected Case of Euglycemic Diabetic Ketoacidosis With Twists.
PG  - e24016
LID - 10.7759/cureus.24016 [doi]
LID - e24016
AB  - Euglycemic diabetic ketoacidosis (EDKA) is defined by acidosis, ketones in serum 
      and urine, and a high anion gap (AG) with a normal glucose level. Sodium-glucose 
      cotransporter-2 (SGLT2) inhibitor has become one of the most common causes of 
      EDKA. We present one of the lowest presenting blood glucose levels for the EDKA 
      in the setting of SGLT2 inhibitor use. A 34-year-old female with a two-year 
      history of type 2 diabetes mellitus (T2DM) presented after accidental ingestion 
      of a metal clip and lack of oral intake for 28 hours. She reported a recent 
      intentional weight loss of 60 lbs. She takes metformin 1000 mg twice daily and 
      empagliflozin 25 mg daily. An urgent endoscopy was planned in the intensive care 
      unit given the proximal location of the foreign body. The basic metabolic profile 
      after the procedure demonstrated a glucose level of 75 mg/dL, bicarbonate level 
      of 11 mmol/L, and AG of 17 mmol/L. The venous pH was 7.27 with a partial pressure 
      of carbon dioxide of 30 mmHg. The urinalysis showed a glucose level greater than 
      500 mumol/L with a ketone level of 80 mumol/L. The blood and urine toxicology 
      screening results were unremarkable. The patient was treated for EDKA with the 
      administration of intravenous (IV) dextrose 5% in water with subsequent 
      initiation of IV insulin. The assessment of her insulin reserve revealed a low 
      C-peptide of 0.36 ng/mL, a high glutamic acid decarboxylase level greater than 
      250 IU/mL, and high zinc transporter 8 (ZnT8) antibodies of 42 U/mL, consistent 
      with an undiagnosed transition to latent autoimmune diabetes in adults (LADA). 
      The blood glucose levels for previously reported cases remain between 90 and 250 
      mg/dL. In this case, the combination of a low carbohydrate diet and prolonged 
      starvation may have led to the impressively low glucose. Additionally, the SGLT2 
      inhibitor use in patients with LADA serves as one of the known risk factors for 
      EDKA. EDKA poses a diagnostic challenge, especially in the ICU setting where 
      there exists a myriad of causes for high AG metabolic acidosis. Additionally, 
      many of the ICU patients are in a ketotic state brought on by prolonged 
      starvation. Therefore, prompt diagnosis and treatment for EDKA require careful 
      history taking and complete investigation for other causes of high AG metabolic 
      acidosis.
CI  - Copyright (c) 2022, Kang et al.
FAU - Kang, Cyra-Yoonsun
AU  - Kang CY
AD  - Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA.
FAU - Khamooshi, Parnia
AU  - Khamooshi P
AD  - Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA.
FAU - Reyes Pinzon, Viviana
AU  - Reyes Pinzon V
AD  - Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA.
LA  - eng
PT  - Case Reports
DEP - 20220410
PL  - United States
TA  - Cureus
JT  - Cureus
JID - 101596737
PMC - PMC9091341
OTO - NOTNLM
OT  - diabetic ketoacidosis (dka)
OT  - euglycemic
OT  - latent autoimmune diabetes in adults (lada)
OT  - sglt-2 inhibitor
OT  - swallowed foreign body
COIS- The authors have declared that no competing interests exist.
EDAT- 2022/05/17 06:00
MHDA- 2022/05/17 06:01
PMCR- 2022/04/10
CRDT- 2022/05/16 04:29
PHST- 2022/04/10 00:00 [accepted]
PHST- 2022/05/16 04:29 [entrez]
PHST- 2022/05/17 06:00 [pubmed]
PHST- 2022/05/17 06:01 [medline]
PHST- 2022/04/10 00:00 [pmc-release]
AID - 10.7759/cureus.24016 [doi]
PST - epublish
SO  - Cureus. 2022 Apr 10;14(4):e24016. doi: 10.7759/cureus.24016. eCollection 2022 
      Apr.