Sydney Guy I
Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut.
AACE Clin Case Rep. 2025 Jan 11;11(2):148-150. doi: 10.1016/j.aace.2025.01.001. eCollection 2025 Mar-Apr.
BACKGROUND/OBJECTIVE: Diabetic ketoacidosis (DKA) is a life-threatening condition typically diagnosed by the presence of hyperglycemia, acidemia, and ketonemia. A subset of patients may develop ketoacidosis without the traditionally increased glucose levels in a condition known as euglycemic DKA. This article describes an atypical presentation of DKA with concomitant hypoglycemia in a condition termed hypoglycemic DKA.
A 74-year-old woman with a history of hypertension, type 2 diabetes mellitus (treated with empagliflozin), and hypothyroidism, presented from an outlying hospital due to concern for acute gallstone pancreatitis and choledocholithiasis. On arrival, laboratory evaluation revealed an anion gap of 16 mEq/L (reference range, 6-12 mEq/L), bicarbonate level of 11 mEq/L (reference range, 21-31 mEq/L), serum glucose level of 57 mg/dL (reference range, 70-105 mg/dL), beta-hydroxybutyrate level of 1.7 mmol/L (reference range, <0.6 mmol/L), and urinalysis demonstrating a ketone level of >80 mg/dL (reference range, <3.49 mg/dL). The patient was treated according to the institution DKA protocol, with resolution of her DKA.
The case presented highlights a manifestation of DKA characterized by a concurrent state of hypoglycemia in a patient treated with a sodium-glucose cotransporter 2 inhibitor, an atypical and likely underreported phenomenon.
Clinicians should maintain a high level of suspicion for DKA in patients with metabolic acidosis and ketosis, irrespective of their glucose levels, in particular in those treated with sodium-glucose cotransporter 2 inhibitors. Additionally, redefining these cases as drug-induced ketoacidosis may assist in preventing delayed diagnosis and management.
背景/目的：糖尿病酮症酸中毒（DKA）是一种危及生命的疾病，通常通过高血糖、酸血症和酮血症来诊断。一部分患者可能在血糖水平未传统性升高的情况下发生酮症酸中毒，这种情况被称为正常血糖性DKA。本文描述了一种在称为低血糖性DKA的情况下伴有低血糖的DKA非典型表现。
一名74岁女性，有高血压、2型糖尿病（使用恩格列净治疗）和甲状腺功能减退病史，因疑似急性胆石性胰腺炎和胆总管结石从外地医院转诊而来。入院时，实验室检查显示阴离子间隙为16 mEq/L（参考范围6 - 12 mEq/L），碳酸氢盐水平为11 mEq/L（参考范围21 - 31 mEq/L），血清葡萄糖水平为57 mg/dL（参考范围70 - 105 mg/dL），β-羟丁酸水平为1.7 mmol/L（参考范围<0.6 mmol/L），尿液分析显示酮水平>80 mg/dL（参考范围<3.49 mg/dL）。患者按照医院的DKA治疗方案进行治疗，DKA得到缓解。
所呈现的病例突出了DKA的一种表现，其特征为在接受钠-葡萄糖协同转运蛋白2抑制剂治疗的患者中同时存在低血糖状态，这是一种非典型且可能未被充分报道的现象。
临床医生对于患有代谢性酸中毒和酮症的患者，无论其血糖水平如何，尤其是那些接受钠-葡萄糖协同转运蛋白2抑制剂治疗的患者，应高度怀疑DKA。此外，将这些病例重新定义为药物性酮症酸中毒可能有助于预防诊断和治疗的延迟。
