Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma

摘要

Euglycemic diabetic ketoacidosis (EDKA) is a clinical triad comprising increased anion gap metabolic acidosis, ketonemia or ketonuria and normal blood glucose levels <200 mg/dL. This condition is a diagnostic challenge as euglycemia masquerades the underlying diabetic ketoacidosis. Thus, a high clinical suspicion is warranted, and other diagnosis ruled out. Here, we present two patients on regular insulin treatment who were admitted with a diagnosis of EDKA. The first patient had insulin pump failure and the second patient had urinary tract infection and nausea, thereby resulting in starvation. Both of them were aggressively treated with intravenous fluids and insulin drip as per the protocol for the blood glucose levels till the anion gap normalized, and the metabolic acidosis reversed. This case series summarizes, in brief, the etiology, pathophysiology and treatment of EDKA.Learning points: class="unordered" style="list-style-type:disc">Euglycemic diabetic ketoacidosis is rare.Consider ketosis in patients with DKA even if their serum glucose levels are normal.High clinical suspicion is required to diagnose EDKA as normal blood sugar levels masquerade the underlying DKA and cause a diagnostic and therapeutic dilemma.Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels. class="head no_bottom_margin" id="__sec2title">BackgroundDiabetic ketoacidosis (DKA) is defined as a clinical triad comprising metabolic acidosis, hyperglycemia and increased ketone bodies in the blood and urine. Hyperglycemia is usually the hallmark for the diagnosis of DKA (). However, there is a subset of patients in whom the serum glucose levels are within the normal limits, and this condition is termed as euglycemic DKA (EDKA). This phenomenon was first described by Munro et al. where 37 out of 211 DKA patients had normal sugar levels (<300 mg/dL) along with a plasma bicarbonate level of <10 mmol/L at presentation (). Later, normoglycemia was redefined as <250 mg/dL. Thus, EDKA is defined as a triad comprising high anion gap metabolic acidosis with positive serum and urine ketones when serum glycemic levels are <250 mg/dL (). In this case series, we report two patients with type I diabetes mellitus (T1DM) who were diagnosed with EDKA. We believe that this case series would serve as a reminder to all practitioners across the world to consider ketosis in a diabetic patient despite their serum glucose levels being within the normal range. This case series summarizes, in brief, the etiology, pathophysiology and treatment of EDKA.