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      Euglycemic Diabetic Ketoacidosis in Type 1 Diabetes on Insulin Pump, with Acute Appendicitis: A Case Report

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          Abstract

          Introduction

          Recently, euglycemic diabetic ketoacidosis has been an increasing topic of discussion within emergency medicine literature. Euglycemic diabetic ketoacidosis can easily be missed, as a normal point-of-care glucose often mistakenly precludes the work-up of diabetic ketoacidosis.

          Case Report

          A 16-year-old female with a past medical history of type 1 diabetes presented to the emergency department with altered mental status, vomiting, and abdominal pain. She was diagnosed with euglycemic diabetic ketoacidosis.

          Conclusion

          Reported cases of euglycemic diabetic ketoacidosis are most frequently attributed to sodium glucose cotransporter-2 inhibitors, but other potential causes have been discussed in the literature. In this patient, a starvation state with continued insulin use in the setting of acute appendicitis led to her condition.

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          Most cited references15

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          Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium–Glucose Cotransporter 2 Inhibition

          OBJECTIVE Sodium–glucose cotransporter 2 (SGLT-2) inhibitors are the most recently approved antihyperglycemic medications. We sought to describe their association with euglycemic diabetic ketoacidosis (euDKA) in hopes that it will enhance recognition of this potentially life-threatening complication. RESEARCH DESIGN AND METHODS Cases identified incidentally are described. RESULTS We identified 13 episodes of SGLT-2 inhibitor–associated euDKA or ketosis in nine individuals, seven with type 1 diabetes and two with type 2 diabetes, from various practices across the U.S. The absence of significant hyperglycemia in these patients delayed recognition of the emergent nature of the problem by patients and providers. CONCLUSIONS SGLT-2 inhibitors seem to be associated with euglycemic DKA and ketosis, perhaps as a consequence of their noninsulin-dependent glucose clearance, hyperglucagonemia, and volume depletion. Patients with type 1 or type 2 diabetes who experience nausea, vomiting, or malaise or develop a metabolic acidosis in the setting of SGLT-2 inhibitor therapy should be promptly evaluated for the presence of urine and/or serum ketones. SGLT-2 inhibitors should only be used with great caution, extensive counseling, and close monitoring in the setting of type 1 diabetes.
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            Euglycemic Diabetic Ketoacidosis: A Review.

            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), metabolic acidosis (arterial pH <7.3 and serum bicarbonate <18 mEq/L) and ketosis. Rarely these patients can present with blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA. The possible etiology of euglycemic DKA includes the recent use of insulin, decreased caloric intake, heavy alcohol consumption, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been reported to present with euglycemia. The recent use of sodium glucose cotransporter 2 (SGLT2) inhibitors has shed light on another possible mechanism of euglycemic DKA. Clinicians may also be misled by the presence of pseudonormoglycemia.
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              Euglycaemic diabetic ketoacidosis.

              Of a series of 211 episodes of diabetic metabolic decompensation 37 had severe euglycaemic ketoacidosis (a blood sugar level of less than 300 mg/100 ml and a plasma bicarbonate of 10 mEq/1. or less). All were young insulin-dependent diabetics, only one being previously undiagnosed. Vomiting was a common factor, and in all carbohydrate reduction occurred with continued or increased daily insulin dose. Treatment comprised fluid and electrolyte replacement and large doses of insulin covered by adequate carbohydrate, many receiving 10% dextrose. Alkali was either withheld or given sparingly and the therapy was monitored by serial estimations of plasma bicarbonate. All the patients survived.
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                Author and article information

                Journal
                Clin Pract Cases Emerg Med
                Clin Pract Cases Emerg Med
                Clinical Practice and Cases in Emergency Medicine
                University of California Irvine, Department of Emergency Medicine publishing Western Journal of Emergency Medicine
                2474-252X
                August 2021
                29 June 2021
                : 5
                : 3
                : 136-138
                Affiliations
                University of Massachusetts Medical School - Baystate Health, Department of Emergency Medicine, Springfield, Massachusetts
                Author notes
                Address for Correspondence: Brian D. Thompson, DO, University of Massachusetts Medical School - Baystate Health, Department of Emergency Medicine, 759 Chestnut St, Springfield, MA 01199. Email: Bthompson0034@ 123456gmail.com .

                Section Editor: Rick A. McPheeters, DO

                Article
                cpcem-5-296
                10.5811/cpcem.2021.1.48905
                8373175
                e3ab99a1-618d-4626-908d-d8d6b979c875
                Copyright: © 2021 Thompson et al.

                This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/

                History
                : 29 June 2020
                : 28 December 2020
                : 11 January 2021
                Categories
                Case Report

                euglycemic diabetic ketoacidosis,emergency medicine

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