What are the signs and symptoms of euglycemic diabetic ketoacidosis (DKA)?

Signs and Symptoms of Euglycemic Diabetic Ketoacidosis

Euglycemic DKA presents with the classic symptoms of diabetic ketoacidosis—including polyuria, polydipsia, nausea, vomiting, abdominal pain, weakness, and altered mental status—but with blood glucose levels less than 250 mg/dL, making it a diagnostic challenge that requires high clinical suspicion. 1, 2

Clinical Presentation

Classic DKA Symptoms (Present Despite Euglycemia)

• Gastrointestinal symptoms: Nausea, vomiting (up to 25% may have coffee-ground emesis), and abdominal pain are common presenting features 3, 1
• Polyuria, polydipsia, and polyphagia with associated weight loss 3, 1
• Weakness and malaise are frequently reported 3, 4
• Dehydration manifesting as poor skin turgor 3, 1

Physical Examination Findings

• Kussmaul respirations (deep, labored breathing pattern) indicating metabolic acidosis 3, 1
• Tachycardia and hypotension from volume depletion 3, 1
• Altered mental status ranging from full alertness to profound lethargy or coma (though coma is more common in hyperosmolar hyperglycemic state) 3, 1
• Normothermia or hypothermia may be present even with underlying infection; hypothermia is a poor prognostic sign 3

Key Diagnostic Challenge

The critical distinguishing feature of euglycemic DKA is that blood glucose levels are less than 250 mg/dL (and often <200 mg/dL), which can mislead clinicians into overlooking the diagnosis 1, 2, 5. This creates a dangerous situation where the severity of metabolic acidosis may be underestimated due to the absence of marked hyperglycemia 6, 2.

Laboratory Manifestations

While not strictly "signs and symptoms," these findings confirm the clinical suspicion:

• Metabolic acidosis: pH <7.3, serum bicarbonate <18 mEq/L 1, 2
• Elevated ketones in blood or urine (β-hydroxybutyrate is the preferred measurement) 1, 2
• Elevated anion gap (>10-12 mEq/L) 1
• Blood glucose <250 mg/dL (often <200 mg/dL) 1, 2, 5

Common Pitfalls to Avoid

The normal or near-normal glucose levels can cause significant diagnostic delay, as clinicians may not consider DKA in the differential diagnosis 6, 2, 7. Blood pH and ketone levels should be checked in any ill diabetic patient regardless of blood glucose levels 7. The vague, non-specific symptoms combined with euglycemia can mask the severity of the metabolic emergency 6.

High-Risk Clinical Scenarios

Be particularly vigilant for euglycemic DKA in patients with:

• SGLT2 inhibitor use (increasingly common cause) 1, 6, 2
• Recent insulin use or insulin pump failure 2, 7
• Decreased caloric intake, fasting, or ketogenic diet 1, 4, 2
• Pregnancy 1, 2
• Heavy alcohol consumption or chronic liver disease 1, 2
• Gastroparesis or recent bariatric surgery 5