Endocrine Abstracts

Introduction: Sodium/glucose co-transporter 2 (SGLT2) inhibitors are a relatively new group of antihyperglycaemic medications for type 2 diabetes mellitus (T2DM). Euglycemic diabetic ketoacidosis (EDKA) and Fournier’s gangrene (FG) are uncommon advers effects of SGLT2 inhibitors. We report a case of a 52-year-old man who developed FG and EDKA after starting the SGLT2 inhibitor empagliflozin.

Case Presentation: A-52 years old male patient attended to the emergency department with bilateral red-swollen perineal lesion of one day evolution. Patient had a history of T2DM under poor glycemic control for 10 years. He was using glyclazide 30 mg/d. He started to use empagliflozin treatment for his high HbA1c levels (12.2 %) two days before the development of the lesion. In suspicion of FG, pelvic CT scan was taken and severe subcutaneous air was reported in the lesion consistent with FG. Emergent surgical debridement was performed and after surgery he was followed in surgical ICU. During follow-up, the patient became tachypneic, lethargic and he had no response to verbal stimulus. The patient had severe acidosis, low bicarbonate level and euglycemia (pH:6.90, bicarbonate 4.9 mEq/l, lactate:1.7 mmol/l, plasma glucose: 189 mg/dl). After diagnosis of EDKA, continuous intravenous regular insulin and saline infusion was started. After 20 h of treatment, patient’s plasma pH level increased to 7.26 and bicarbonate level increased to 19.9 mEq/l. His state of counciousness improved and GCS scored 15. The patient is still under intensive insuline therapy, antibiotherapy and negative pressure dressing for FG.

Conclusions: FG is a necrotizing infection of the tissue under the skin of the perineum. The incidence is 1.6 cases per 100×000 population. Poorly controlled diabetes, obesity, chronic alcoholism and immunosuppression are risk factors for FG. The duration of FG development after the use of SGLT2 inhibitors varies between 10 days and 6 years in the literature. In our patient, FG developed in a very short time, 2 days after starting SGLT2 inhibitor. EDKA is a clinical feature in which blood sugar is within normal limits, accompanied by acidosis and ketosis. In the perioperative setting, typical signs and symptoms of EDKA can confound the diagnosis and mistakenly be attributed to clinical presentations during the postsurgical state. EDKA, should be considered in the differential diagnosis and treatment should be started without delay. It is imperative that clinicians evaluate the benefits and risks associated with SGLT-2 inhibitors in diabetic patients at high risk of FG who do not use insulin.