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.