What are the clinical symptoms of euglycemic diabetic ketoacidosis in a diabetic patient, especially one taking a sodium‑glucose cotransporter‑2 inhibitor, who is pregnant, fasting, or recently ill or post‑operative?

Symptoms of Euglycemic Diabetic Ketoacidosis

Euglycemic DKA presents with the classic symptoms of ketoacidosis—nausea, vomiting, abdominal pain, weakness, and malaise—but with blood glucose levels below 200-250 mg/dL, making it easily missed if clinicians rely solely on hyperglycemia for diagnosis. 1, 2, 3

Core Clinical Presentation

The symptom complex mirrors traditional DKA but occurs with deceptively normal or mildly elevated glucose:

• Gastrointestinal symptoms: Nausea, vomiting, and abdominal pain are prominent features 4, 5, 6
• Constitutional symptoms: Malaise, fatigue, generalized weakness, and lethargy 7, 5, 6
• Classic diabetic symptoms: Polyuria and polydipsia may precede the acute presentation 4, 8
• Dehydration signs: Poor skin turgor and signs of volume depletion 4
• Respiratory changes: Kussmaul respirations (deep, labored breathing) may be present as compensation for metabolic acidosis 4

High-Risk Clinical Contexts

Euglycemic DKA should be suspected particularly in these scenarios:

SGLT2 Inhibitor Use

• Most common contemporary cause: Patients on empagliflozin, dapagliflozin, or canagliflozin presenting with ketoacidosis symptoms despite normal glucose 2, 3, 5
• Symptoms can develop even after drug discontinuation if precipitating factors persist 9, 3

Pregnancy

• Pregnant individuals with pregestational diabetes (especially type 1) may present with euglycemic DKA and glucose <200 mg/dL 1
• Mixed acid-base disturbances and hyperemesis can further complicate diagnosis 1
• Incidence approaches 2% in pregnancies with pregestational diabetes 1

Fasting or Reduced Caloric Intake

• Very-low-carbohydrate or ketogenic diets precipitate euglycemic DKA through severe carbohydrate restriction 1, 2, 3, 7
• Prolonged fasting, poor oral intake during illness, or persistent vomiting create a carbohydrate-deficit state 1, 3, 10

Acute Illness or Post-Operative State

• Infection (especially urinary tract infection and pneumonia) is the most common precipitating factor overall 4, 9, 5
• Surgical stress triggers counterregulatory hormone surge (glucagon, catecholamines, cortisol, growth hormone) that persists for days postoperatively 9
• Emergency surgery carries 6.5-fold higher DKA risk than elective procedures 9
• Myocardial infarction, cerebrovascular accident, and trauma can all precipitate euglycemic DKA 4, 2

Recent Insulin Use

• Insulin administration prior to presentation lowers glucose while ketoacidosis persists, creating the euglycemic picture 2, 10
• Inadequate insulin dosing during NPO periods or illness contributes to development 9

Critical Diagnostic Pitfalls

The most dangerous aspect of euglycemic DKA is that normal or near-normal glucose levels provide false reassurance, leading to delayed recognition and treatment. 2, 3, 6

Key Warning Signs Not to Miss:

• Metabolic acidosis with pH <7.3 and elevated anion gap despite reassuring glucose 3, 7, 6
• Elevated ketones (blood or urine) in the presence of acidosis 3, 7, 6
• Nonspecific symptoms (malaise, nausea, vomiting) may be incorrectly attributed to other causes like gastroenteritis or surgical recovery 3
• Patients may be alert and oriented rather than obtunded, unlike hyperglycemic DKA 4

Mental Status Considerations

• Mental status can vary from full alertness to profound lethargy, with altered consciousness being less common than in hyperglycemic DKA 4
• Clouding of sensorium may progress to coma in severe cases, though this is more typical of hyperosmolar hyperglycemic state 4

Temperature and Hemodynamic Findings

• Patients can be normothermic or even hypothermic despite infection due to peripheral vasodilation 4
• Hypothermia, when present, is a poor prognostic sign 4
• Tachycardia and hypotension reflect volume depletion 4
• Shock may develop in severe cases 4

Specific Populations Requiring Heightened Vigilance

• Type 1 diabetes patients or those with latent autoimmune diabetes misdiagnosed as type 2 diabetes 2
• Patients with pancreatic insufficiency 2
• Those on corticosteroids or atypical antipsychotics, which increase insulin resistance 2
• Patients with excessive alcohol consumption 1, 2, 3

The cornerstone of avoiding missed diagnosis is checking ketones and arterial pH in any diabetic patient with symptoms of ketoacidosis, regardless of glucose level, especially in the high-risk contexts outlined above. 1, 3, 6