A Case of Euglycemic Diabetic Ketoacidosis (DKA), Influenza, and a Dipeptidyl Peptidase-4 (DPP-4) Inhibitor

A subclass of diabetic ketoacidosis (DKA) is euglycemic DKA, characterized by the same traits of ketoacidosis and low bicarbonate levels. However, the condition differs from classic DKA because of its normoglycemic levels. Euglycemic DKA was once thought to be incredibly rare, but its incidence has been on the rise with the widespread use of sodium-glucose-cotransporter-2 (SGLT2) inhibitors and other newer anti-diabetic medications. The disorder is not fully understood and is often missed when presenting because of the non-elevated blood sugars. Common triggers for euglycemic DKA include infection, fasting, pregnancy, and medications such as SGLT2 inhibitors. This case report involves a patient with type 2 diabetes mellitus on sitagliptin that presented to the emergency department with shortness of breath, cough, nausea, vomiting, and abdominal pain and tested influenza positive with blood glucose levels of 209 mg/dl. He was started on IV fluids and subcutaneous insulin but developed worsening acidosis. The following day, he was transferred to the ICU for DKA protocol and diagnosed with euglycemic DKA.