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Euglycemic Diabetic Ketoacidosis: An Easily Missed Diagnosis FREE TO VIEW

Karim Nathan, MD; Abhishek Agarwal, MD; Abhinav Agrawal, MD; Deborah Park, MD
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Cooper University Hospital, Philadelphia, PA

Chest. 2015;148(4_MeetingAbstracts):255A. doi:10.1378/chest.2281396
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SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: A 47 year-old woman with type 1 diabetes presented with euglycemic diabetic ketoacidosis (DKA) that initially went undiagnosed. Recognition and treatment with insulin resulted in rapid resolution of her clinical condition.

CASE PRESENTATION: A 47 year-old woman presented to our hospital with four days of fever, abdominal pain, diarrhea, nausea, vomiting, lethargy and malaise. She had a history of type 1 diabetes mellitus managed with an insulin pump. Her blood pressure was 88/51. She was disoriented with a diffusely tender but soft abdomen. Laboratory studies revealed blood glucose of 109 mg/dL, bicarbonate of 15 mmol/L, anion gap of 27 mmol/L, lactic acid of 2.4 mmol/L, and a bandemia of 11%. Rapid flu test was positive. She was admitted to the intensive care unit, resuscitated with intravenous fluid, and started on oseltamivir, cefepime and vancomycin. Hemodialysis was initiated soon thereafter. The patient received no insulin due to her euglycemia. Influenza A was detected by PCR on the second hospital day and antibiotics were discontinued. Her gastrointestinal symptoms improved but her mental status remained poor. Furthermore, while her lactate normalized and blood glucose remained under 120 mg/d, her anion gap persisted at 23-36 mmol/L and her bicarbonate remained low at 15-17 mmol/L. Beta hydroxybutyrate was found to be 4.88 mmol/L. An insulin infusion was started, along with dextrose 5% in water, and her mental status rapidly improved as her acidemia and anion gap normalized.

DISCUSSION: Euglycemic DKA is a rare condition that can easily go undiagnosed. It has been previously described in the context of critical illness.1 The pathogenesis may involve an accelerated rate of ketosis in the setting of decreased caloric intake or fasting,2 along with increased levels of glucagon and catecholamines, both of which increase lipolysis.2 Many other conditions can present with eugylcemia acidosis in a diabetic patient and should be considered. These include lactic acidosis and starvation ketosis.2 However, unlike starvation ketosis, euglycemic DKA is a distinct clinical entity resulting from severe insulin deficiency, and can be differentiated from the former by the presence of a precipitating clinical illness,2 a bicarbonate concentration lower than 18 mmol/L,2 and as we have seen, very rapid resolution of laboratory and clinical abnormalities with administration of insulin.

CONCLUSIONS: Eugylcemic DKA is a clinical entity distinct from starvation ketosis. It should be included in the differential of all critically ill diabetic patients with an anion-gap acidosis, and should be treated promptly with insulin.

Reference #1: John R, Yadav H, John M. Euglycemic ketoacidosis as a cause of a metabolic acidosis in the Intensive Care Unit. Acute Med. 2012;11(4):219-21.

Reference #2: Joseph F, Anderson L, Goenka N, Vora J. Starvation-induced true diabetic euglycemic ketoacidosis in severe depression. J Gen Intern Med. 2009 Jan;24(1):129-31.

DISCLOSURE: The following authors have nothing to disclose: Karim Nathan, Abhishek Agarwal, Abhinav Agrawal, Deborah Park

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