Euglycaemic diabetic ketoacidosis as complication of upper gastrointestinal bleed in a patient with underlying Type 2 diabetes

INTRODUCTION

Diabetic ketoacidosis (DKA) is one of the most serious complications of both type 1 and type 2 diabetes and is associated with high mortality between 1-5%. Euglycaemic DKA on the other hand is defined by Random Blood sugar (RBS) of more than 11 mmol/l with metabolic acidosis (pH < 7.35) and ketonaemia (>2) and few causes have been implicated; among them in Type 1 diabetes, pregnancy and resent use of SGLT-2 inhibitors in a diabetic patient.

CASE DESCRIPTION

We describe a case of a 69 year old gentleman with underlying Hypertension, Type 2 diabetes and chronic kidney disease stage 4. She presented with a week history of lethargy, black-tarry stool, poor oral intake and haematemesis for 1 day. On further questioning she has history of taking traditional medications. Examination reveals palor and mild epigastric tenderness, no stigmata of chronic liver disease, mildly dehydrated and insertion of nasogastric tube reveals coffee ground. Vital signs showed tachycardia (heart rate 120) but normotensive. Blood investigations reveal normochromic normocytic anaemia with Hb 4 and disproportionately increase in urea and creatinine (urea 18, cr 243) in keeping with diagnosis of upper gastro-intestinal bleed. Capillary blood glucose (CBG) 9 mmol/l and there was no acidosis on venous blood gas (VBG).

She was kept nil-by-mouth, transfused 2 pints packed cell and infused with proton-pump-inhibitor while awaiting for gastroscopy. 6 hours into admission, she was noted to have heavy breathing and repeated blood investigation showed acidosis VBG: pH 7.21, HCO3 11 with CBG of 8mmol/l, lactate 1.2 .Serum ketone was high at 6 mmol/l. Diagnosis of euglycaemic DKA was made and she was treated with standard treatment of DKA with fluid resuscitation  with normal saline, intravenous insulin and glucose infusion and 12 hours later, ketoacidosis resolved, PH 7.35, HCO3 25, Ketone 1.2. She proceeded with gastroscopy which revealed 2 Duodenal ulcer IIC

LEARNING POINT and CONCLUSION

This case illustrates the need to have high index of suspicion for diagnosis of euglycaemic diabetic ketoacidosis when a diabetic patient with multiple comorbidities such as chronic renal failure, upper gastro-intestinal bleed and starvation when acidosis is present even in the setting of a normal CBG.

In conclusion, investigating for level of serum ketone in unexplained acidosis in patients with diabetes after excluding other causes could be the way forward to better recognise euglycaemic DKA and institute treatment appropriately.