EUGLYCEMIC DIABETIC KETOACIDOSIS

ELUSIVE, YET A DIAGNOSIS NOT TO BE OVERLOOKED IN CASES OF UNEXPLAINED METABOLIC ACIDOSIS

Abstract

INTRODUCTION
Euglycemic diabetic ketoacidosis is a rare but serious condition. The absence of hyperglycemia frequently causes a delay in diagnosis and treatment initiation. We present a case of acute coronary syndrome in cardiogenic shock in which the euglycemic DKA diagnosis was missed.

CASE
A 65-year-old female with underlying diabetes mellitus, hypertension, chronic kidney disease and ischemic heart disease presented with typical chest pain and heart failure symptoms. Patient was tachypneic with Grd 2 edema, BP 107/58 mm Hg, HR 98 beats/min, SpO₂ 89% at room air and blood glucose 6.3 mmol/L. Electrocardiogram had dynamic changes. Initial blood investigations showed urea 15.3 mmol/L, sodium 133 mmol/L, K 4.4 mmol/L, Cl 105 mmol/L, creatinine 376 µmol/L, pH 7.236, lactate 6.7 mmol/L, bicarbonate 12.2 mmol/L and anion gap 16.6 mmol/L. Bedside ultrasound revealed ejection fraction of 40-50%, RWMA, plethoric IVC measuring 2.3 cm. As the patient's blood pressure dropped, noradrenaline was administered with the furosemide infusion. The patient was assessed to have acute decompensated heart failure in cardiogenic shock secondary to acute coronary syndrome and acute on chronic kidney disease. Despite optimal doses of diuretics, there was no urine output. Dialysis was initiated due to refractory fluid overload. Venous blood gas post dialysis showed pH 7.184, HCO₃ 11.5 mmol/L, glucose 7 mmol/L, lactate 1.6 mmol/L and anion gap 17 mmol/L. Despite dialysis and improved serum lactate levels, the metabolic acidosis worsened. Capillary ketone was taken for unexplained acidosis showing an alarming value of 4.3 mmol/L, confirming the diagnosis of euglycemic DKA. Insulin infusion with dextrose was initiated. Follow-up VBG indicates an improvement of pH to 7.273 and HCO₃ to 13.6 mmol/L.

CONCLUSION
Failure to recognize euglycemic DKA may lead to catastrophic outcomes. Clinicians must maintain a high index of suspicion in high-risk populations and advocate for ketone testing in unexplained metabolic acidosis, regardless of glucose levels. Early recognition and targeted therapy can rapidly reverse acidosis and prevent morbidity.