Euglycemic DKA in a DPP-4 inhibitor patient following traumatic brain injury: A complex ICU glucose management challenge.

RATIONALE

Euglycemic diabetic ketoacidosis (EuDKA) is a rare variant of diabetic ketoacidosis (DKA), characterized by normal or near-normal glucose levels despite severe metabolic acidosis and ketosis. This condition poses a diagnostic challenge as it mimics DKA without the hallmark hyperglycemia. Recent studies have suggested an association between EuDKA and newer antidiabetic medications, including dipeptidyl peptidase-4 (DPP-4) inhibitors.

PATIENT CONCERN

A 57-year-old male with a history of type 2 diabetes, hypertension, ischemic heart disease, and rheumatoid arthritis developed EuDKA following a traumatic brain injury. Despite a blood glucose of 134 mg/dL, he exhibited classic features of DKA, including severe metabolic acidosis, low bicarbonate levels, an elevated anion gap, and positive urinary ketones.

DIAGNOSIS

Despite the blood glucose level being within normal range, the patient's clinical presentation, including severe acidosis (pH 7.16), low bicarbonate (2.8 mmol/L), elevated anion gap (24.9 mmol/L), and urinary ketones, pointed to EuDKA. The patient's use of Sitagliptin, a DPP-4 inhibitor, was identified as a likely precipitating factor.

INTERVENTIONS

Timely interventions, including fluid resuscitation, insulin therapy, and electrolyte correction, were promptly administered to manage the patient's metabolic abnormalities.

OUTCOME

After receiving intensive treatment, the patient made a full recovery with normalization of metabolic parameters and no long-term complications.

LESSONS

This case emphasizes the importance of maintaining a high index of suspicion for EuDKA in trauma patients, particularly those on DPP-4 inhibitors. Early recognition and prompt intervention are crucial to preventing complications and ensuring positive outcomes. Further research is needed to explore the mechanisms linking DPP-4 inhibitors with EuDKA, especially in the context of metabolic stress like traumatic brain injury.