EUGLYCAEMIC DKA CASES

TWO CAUTIONARY TALES

Abstract

INTRODUCTION
Euglycaemic diabetic ketoacidosis (euDKA) presents with a triad of high anion gap metabolic acidosis, ketonemia and normal blood glucose. It has been increasingly reported with the increased use of SGLT-2 inhibitors. Here, we describe two euDKA cases of different aetiologies.

CASES
The first case is a 29-year-old pregnant female with type 1 diabetes diagnosed at 8 years old with good control pre-partum (HbA1C 6.8%) and only 1 previous DKA at diagnosis. During pregnancy, glycaemic control worsened, requiring high doses of insulin. She presented at 33 weeks of gestation with reduced fetal movement alongside epigastric discomfort, vomiting and dyspnoea. Ultrasound by her obstetrician revealed no fetal movement and investigations showed high anion gap metabolic acidosis with pH 6.9, bicarbonate 12 nmol/l while capillary blood glucose (CBG) was 10.3 mmol/l and serum ketone was 6.5 mmol/l. EuDKA precipitated by intrauterine death was diagnosed, treatment was started and patient underwent C-section. Postoperatively, acidosis and ketonaemia resolved and CBG was controlled with low dose insulin.

The second case is a 56-year-old female with poorly-controlled type 2 diabetes (HbA1c 12%) who was diagnosed with upper gastrointestinal bleeding. Blood investigations showed CBG 8.5 mmol/l, normal blood gasses and disproportionate urea:creatinine ratio. She was kept nil by mouth while waiting for gastroscopy. Eight hours later she developed tachypnoea and worsening epigastric pain; repeat blood investigations showed pH 7.0, bicarbonate 17 nmol/l, CBG 11 mmol/l and serum ketone 4.3 mmol/l. EuDKA was diagnosed and she was treated promptly and acidosis and ketonaemia resolved.

CONCLUSION
These two cases illustrate the need for a high index of suspicion for euDKA in diabetics undergoing stressful conditions and the importance of measuring serum ketone in metabolic acidosis even in patients with normal blood glucose.