Celine Mansour, Emile Katrib, Myriam Mansour, Mirna Fares
Euglycemic diabetic ketoacidosis (EDKA) is a complication of sodium-glucose cotransporter-2 (SGLT2) inhibitors that is being increasingly documented. It is challenging to diagnose, especially in critically ill patients because hyperglycemia is absent or mild. We report the case of a 71-year-old man with type 2 diabetes mellitus previously treated with dapagliflozin, which had been discontinued 2 weeks before presentation, who was admitted for tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement in the context of a neurodegenerative disorder. On postoperative day 2, he was transferred to the intensive care unit (ICU) for aspiration pneumonia complicated by septic shock. He subsequently experienced recurrent episodes of high anion gap metabolic acidosis associated with positive ketonuria and relative euglycemia. The initial episode was interpreted as mixed septic lactic acidosis and SGLT2 inhibitor-associated EDKA, whereas later episodes were more consistent with isolated recurrent EDKA. Management consisted of treatment of the underlying septic shock, and repeated courses of fixed intravenous (IV) insulin infusions to close the anion gap while maintaining euglycemia. This case demonstrates the importance of suspecting EDKA, especially in critically ill patients on SGLT2 inhibitors who present with unexplained high anion gap metabolic acidosis, even when lactic acidosis is present. Early diagnosis and treatment are essential to prevent complications and relapse.