Endocrine Abstracts

Background

Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. It is characterised by the triad of hyperglycemia (blood sugar >250 mg/dl), ketosis and metabolic acidosis (arterial pH <7.3 and serum bicarbonate <18 mEq/l). Rarely these patients can present with blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA.

Case

A 22-year-old female patient applied to the primary care physician with tingling and numbness in the hands. Fasting blood glucose was 205 mg/dl with normal renal and liver function tests in the first laboratory evaluation and then suggested to apply to the endocrinology clinic. After learning about high blood sugar level, she avoided foods containing carbohydrates and followed a ketogenic diet. She is 160 cm tall and 45 kg heavy. The patient referred to the endocrinology clinic with nausea two weeks later. Her plasma glucose level was 86 mg/dl with an HbA1C of%10.3. HbA1C measurement was repeated and confirmed to be high. She was diagnosed with diabetes. Her laboratory assessments revealed an elevated anion gap of 20.9, increased urinary and plasma ketones, and metabolic acidosis. Low hCG values excluded pregnancy The diagnosis of euglycemic DKA was made, and treatment with intravenous fluids and insulin was initiated, then the patient improved.The C-peptide level was 0.42 µg/l (n:0.81–3.85 low normal). Anti-glutamic acid decarboxylase and anti-insulin antibodies were negative, while the anti-islet cell antibody was positive. There was no one with diabetes in her family. She was screened for liver diseases and glycogen storage diseases, and no pathological condition was detected.

Conclusion

We present a type 1 diabetic patient diagnosed with euglycemic DKA. The possible aetiology of euglycemic DKA includes decreased caloric intake, heavy alcohol consumption, the recent use of sodium-glucose cotransporter 2 inhibitors, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been reported to present with euglycemia. Our patient had euglycemic DKA triggered by the ketogenic diet. Euglycemic DKA can be missed or inadequately treated in patients presenting with euglycemia on initial presentation. Recognising this condition in newly diagnosed patients can also be a challenge for physicians.