13 Aug 2020

7/29/2020: Euglycemic DKA 2/2 SGLT-2 Inhibitor

PGY2 Jonathan Pai presented a case of a 47 y/o male with history of non-insulin dependent DM Type 2 complicated by diabetic retinopathy, neuropathy, RLE toe amputation and b/l peripheral vascular disease presents with fevers/chills, nausea, NBNB emesis x4 days. The patient also noticed a new R heel ulcer about 5 days prior to admission. Denies any sick contacts, recent trauma/travel. His home medications were significant for Syndjardy XR (Jardiance + Metformin). Denies any ETOH/drug/tobacco use.

CBC: WBC 10.2> Hb 14.1/Hct 41.5 <Plt 275
BMP: Na: 136/K: 4.2/Cl: 96/HCO3: 18/BUN: 22/Cr: 1.24 < Glucose: 189 (Anion Gap: 22)

VBG: 7.39/26/40/16
UA: +glucose, +ketones, +protein
ESR: 82, CRP: 384
BCx: MSSA 2/4 bottles
Lactate: 1.2 (normal)

XR and MRI:

MRI Read:

  • In the absence of a ulcer at the 4th MTP joint, T1/STIR signal abnormality changes of the 4th proximal phalanx/metatarsal are nonspecific but osteomyelitis is considered less likely given presence of interspersed fat signal. Differential considerations include reactive changes, bony infarct, or stress related changes

Echo Read: No vegetations

Beta-hydroxybuturate: 4.84

Diagnosis: Euglycemic DKA 2/2 SGLT-2 inhibitor and Bacteremia 2/2 OM

Treatment: Admitted to MICU for insulin and D5 gtt. Pt received IVF. XR R foot c/w osteomyelitis, started on Vancomycin, Ceftriaxone, and Flagyl (narrowed after culture results). Endocrine was consulted for further insulin recs and recommended discontinuing SGLT inhibitor, resuming metformin, Ozempic, and Lantus.

Sentinel Article:
Euglycemic DKA

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