Introduction: Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes.
It is characterised by the triad of hyperglycemia (blood sugar >250 mg/dl), metabolic acidosis
(arterial pH <7.3 and serum bicarbonate <18 mEq/L) and ketosis. Rarely these patients can present with
blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA. The possible
etiology of euglycemic DKA includes the recent use of insulin, decreased caloric intake, heavy alcohol
consumption, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been
reported to present with euglycemia. The recent use of sodium glucose cotransporter 2 (SGLT2) inhibitors
has shed light on another possible mechanism of euglycemic DKA. Clinicians may also be misled
by the presence of pseudonormoglycemia.
Conclusion: Euglycemic DKA thus poses a challenge to physicians, as patients presenting with normal
BG levels in ketoacidosis may be overlooked, leading to a delay in appropriate management strategies.
In this article, we review all the possible etiologies and the associated pathophysiology of patients presenting
with euglycemic DKA. We also discuss the approach to diagnosis and management of such
patients. Despite euglycemia, ketoacidosis in diabetic patients remains a medical emergency and must
be treated in a quick and appropriate manner.
Keywords: Diabetic ketoacidosis, euglycemia, starvation, alcohol, SGLT-2 inhibitors, pregnancy, pseudo-normoglycemia.
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