Euglycaemic diabetic ketoacidosis

Abstract

A74-year-old woman with insulin-dependent diabetes was admitted to the medical high dependency unit with a 2-day history of increasing nausea and confusion. On examination she was afebrile, dehydrated and confused. Systemic examination was unremarkable. Capillary blood glucose by self-monitoring strip was 10.6 mmol/litre and urinalysis demonstrated 3+ ketones and 3+ glucose. Biochemical examination revealed plasma glucose 11.9 mmol/litre, sodium 127 mmol/litre, potassium 5.1 mmol/litre, urea 13.9 mmol/litre and creatinine 87 mmol/litre. Arterial blood gas analysis showed pH 7.30, partial pressure of carbon dioxide = 4.4 kPa, partial pressure of oxygen = 9.0 kPa, bicarbonate = 15.3 mmol/litre, base excess -9.2 mmol/litre and oxygen saturation 97%. She was treated with intravenous dextrose-saline and low dose insulin infusion. She made a good recovery and was well within 48 hours of presentation.

Diabetic euglycemic ketoacidosis in newly diagnosed type 1 diabetes mellitus during Ramadan fasting

“…Although blood glucose levels are generally high, only cases of pregnant women with moderately increased blood glucose concentrations and long-lasting starvation have been reported (4)(5)(6)(7)(8). It was discussed here that normal blood glucose levels might be diagnosed in patients applying with DKA while discussing the newly diagnosed type 1 diabetes mellitus patients, who had long-lasting starvation during the month of Ramadan.…”

“…In that study, in which they reported the absolute euglycemic ketoacidosis was 0.8%-1.1% in all attacks, they suggested that cutoff value for blood glucose would be 200 mg/dL (11 mmol/L) to define the absolute euglycemic DKA in adults (4). It was suggested that the relatively lower blood glucose observed in those patients was the result of continuous vomiting with low carbohydrate intake (4)(5)(6)(7)(8).…”

“…Although DKA is related to high blood glucose levels, at a great extent, only moderately elevated blood glucose concentrations may be observed, and this condition is defined as euglycemic ketoacidosis. This condition, called euglycemic DKA, is being reported in pregnant women, depressed insulin-dependent diabetics, and alcoholics (4)(5)(6)(7). Except for these conditions, glycogen storage diseases and chronic liver disease may result in euglycemic ketoacidosis by causing decreased glycogen storages, and they should be considered in the differential diagnosis (6)(7)(8).…”

Diabetic ketoacidosis without hyperglycemia as a complication of SGLT2 inhibitors treatment

“…The primary cause of acidosis developing in the patients was decreased carbohydrate intake due to vomiting or starvation, oc- casionally coupled with reduced insulin dose. In later years it was accepted that serum glucose concentration in euglycemic ketoacidosis is ≤ 200 mg/dl (11,1 mmol/l) [32,33]. However, it is not a value which could be defined as normoglycemia.…”

Starvation-induced True Diabetic Euglycemic Ketoacidosis in Severe Depression

“…Based on this criterion, only 16 of the 37 episodes in the study by Munro et al and 6 of the 23 episodes in the study by Jenkins et al could be described as true euglycemic DKA 2,3 . The suggested etiology for the relatively low blood glucose seen in this condition is the low caloric intake precipitated by starvation and persistent vomiting together with continuation of insulin treatment 2,3,5 . We report a case of true euglycemic ketoacidosis that highlights firstly the need for assessment of acid/base status in patients with type 1 diabetes presenting with nausea, vomiting, and decreased oral intake, even when the circulating glucose concentration is in the normal range, and secondly that in such patients severe depression may be a cause of the anorexia and starvation.…”