euglycemic DKA

1. Euglycemic DKA: A diagnosis
that cannot be missed
DR AFIFI /SALMA/ SYAFIQ

2. History
• 46-year-old Chinese Lady
• Underlying : Diabetes Mellitus and Hypertension
• Recently discharged from Hospital in Bali Indonesia for CVA with right
sided hemiparesis and referred to Tung Shin Hospital Kuala Lumpur
for rehabilitation ( 28/11/2022)
• Medication :
• T empaglifozin 10mg OD
• T Amlodipine 10mg OD
• T Rosuvastatin 20mg ON
• T Esomeperazole 40mg OD

3. HOPI
• Presented to Emergency Department with history of :
• post prandial vomiting x5/7
• oral ulcer 5/7
• reduce oral intake x3/7
• unable to tolerate orally due to vomiting
• Otherwise: No fever, No URTI symptoms, No UTI symptoms.
• Denied CTD symptoms, no history of miscarriage
• Social History: Divorced , Living with brother

4. Examination at ED
• O/E: Alert , Lethargic looking, tongue coated, lips dry, gag reflex present
• BP 139/90mmhg
• HR 121
• Spo2 98%
• T 37
• DXT 11 repeated 7.8
• Lung Clear
• CVS Dual Rhythm No Murmur
• PA Soft non tender

5. CNS examination
Right Left
Upper limb power 0/5 Upper limb power 5/5
Tone Hypotonia Tone normal
Reflex Brisk Reflex normal
Lower limb power 0/5 Lower limb power 5/5
Tone Hypotonia Tone normal
Reflex brisk Reflex normal
Babiniski Equivocal Babiniski Equivocal

6. Investigation at ED
• FBC : Hb 14.9 , TWC 8.6, Platelet 262
• RP : Sodium 131, potassium 3.3, chloride 99, urea 8.9, creatinine 108
• LFT : albumin 44, AST 34, ALT 21, T bilirubin 11
• UFEME : Protein 2+, ketone 3+
• VBG: PH 7.23, HCO3 12.4, lactate 1.7
• CRP 0.76

7. CXR upon
arrival at ED

8. Manaegement at ED
• Impression:
1. AKI with metabolic acidosis secondary to poor oral intake and
dehydration
2. Underlying CVA with right sided hemiparesis
• Patient was given IVD 1L NS bolus at ED and maintainance with IVD
4pint NS over 24H.
• Admitted to ward

9. Admission in ward
• Patient still lethargic looking, Clinically dehydrated, tongue coated,
lips dry
• Send serum ketone stat : 5.7mmol
• DXT 7.8 ( Ranging from 7.0 - 8.9mmol)
• Repeated VBG : PH 7.23 , HCO3 12.9, Lactate 0.9
• Anion Gap : 20
• Revised Impression :
1. Euglycemic DKA secondary to SGLT2I ( Empaglifozin)
2. Young Stroke for investigation

10. Management
• Started on DKA regime
• Total Fluid boluses 8L + IVI insulin fixed scale 0.05unit/kg + concurrent
IVD D10% 6pint over 24H
• Serum Ketone 5.8mmol > 6.3mmol > 0.8mmol
• VBG after fluid boluses : PH 7.324, HCO3 19.4,lactate 1.4
• DKA resolved within 16 hours

11. Other investigation for young stroke workup
• ECHO : Pending
• C3 and C4 : 0.82 and 0.35 ( normal)
• ANA : pending
• TFT : FT4 10.9 , TSH 0.49
• Cortisol: 631
• 24H urine catecholamine: pending
• Planning for MRI brain and ultrasound carotid doppler outpatient.

12. Euglycemic DKA
• DKA is among the most serious complication of T2DM
• Mortality rate is high if unrecognised. The overall mortality is <1% but
up to 5% in elderly.
• Diagnostic criteria of DKA :
1. Capillary plasma glucose > 11mmol
2. Capillary ketone > 3mmol/L or urine ketone > 2+
3. Venous PH < 7.3 and or Bicarbonate < 15mmol/L
• The current definition of euglycemic DKA is when plasma glucose is
less than 11mmol

13. Euglycemic DKA
• Approximately 10% of patient with DKA present with near normal
glycaemic values
• Recently there is increasing number of cases of euglycemic DKA
• Clinical presentation is similar with DKA.
• A high index of suspicion is required for timely diagnosis especially
when patient is on SGLT2I , poor oral intake, prolonged fasting , post
operative , preganacy or in acute illness

14. Pathophysiology
• Ketosis results from restriction of carbohydrate usage with increased
reliance on fat oxidation for energy production.
• Briefly, absolute insulin deficiency leads to reduced glucose
utilization and enhanced lipolysis
• increased delivery of free fatty acids (FFAs) to the liver coupled with
raised glucagon levels promotes FFA oxidation and production of
ketone bodies

16. Management of Euglycemic DKA
• Treatment should follow standard DKA management protocol
• Dextrose (10% or 5%) and intravenous infusion of insulin must be
used until the anion gap and metabolic acidosis is corrected
• SGLT2I should be withheld and restarted when ketoacidosis resolves
and patient is tolerating food intake
• The resolution of DKA is defined as pH > 7.3 , bicarbonate > 15.0
mmol/L and blood ketone level < 0.6 mmol/L

18. • Case series of adult patient >18 years old with euglycemic DKA
• The study setting in a large tertiary academic centre in USA
• Case was retrospectively screened and identified via ED encounter
diagnosis of DKA
• Initial laboratory values compatible with EuDKA (serum glucose <250
mg/dL, pH < 7.30, HCO3 < 18, anion gap >10)
• 380 cases of DKA only 5 patients with SGLT2I associated euglycemic
DKA ( 1%)

20. Take Home Message
• Normal glucose does not rule out DKA.
• Euglycemic DKA is not an uncommon complication nowadays due to
increased use of SGLT2I recently
• We must have high index of suspicion in patients using SGLT2I
• Treatment should follow standard DKA management protocol.