# Recurrent Euglycemic Diabetic Ketoacidosis Precipitated by Diabetic Myonecrosis in a Patient with Type 1 Diabetes Mellitus

## TL;DR

A patient with type 1 diabetes experienced repeated euglycemic diabetic ketoacidosis linked to diabetic myonecrosis and SGLT2 inhibitor use.

## Contribution

This case highlights a rare recurrence of eDKA precipitated by diabetic myonecrosis in a patient on SGLT2i.

## Key findings

- eDKA recurred 7 to 12 days after the last SGLT2i dose despite normal blood glucose levels.
- Diabetic myonecrosis was identified as a precipitating factor for eDKA recurrence.
- Insulin infusion resolved eDKA episodes, and surgical debridement was performed for myonecrosis.

## Abstract

Euglycemic diabetic ketoacidosis (eDKA) is a well-recognized complication with sodium linked cotransport of glucose-2 inhibitor (SGLT2i) use. Recurrent eDKA is an infrequently described entity. We describe a patient with recurrent eDKA precipitated by diabetic myonecrosis.

A 48-year-old male with Diabetes Mellitus treated with empagliflozin and insulin, presented with left thigh pain and anorexia. Physical examination was notable for BMI 16 kg/m2 and left thigh tender induration. Laboratory evaluation revealed pH 7.1, bicarbonate 10 mmol/L, anion gap 32 mmol/L, glucose 168 mg/dl, erythrocyte sedimentation rate 67 mm/hr, Creatine Kinase 31 U/L, glucosuria (4+), ketonuria (4+), HbA1c 11.3%, C-peptide <0.5 ng/ml and glutamic acid decarboxylase antibody titer 64.3 IU/ml. He was diagnosed with eDKA due to SGLT2i use. Empagliflozin was discontinued. MRI of the left thigh revealed diabetic myonecrosis. He was treated with insulin infusion leading to eDKA resolution on hospital day 3. On hospital day 5, bicarbonate was 15 mmol/L, anion gap 18 mmol/L, beta-hydroxybutyrate 49.6 mg/dl, glucose 185 mg/dl, glucosuria (4+) and ketonuria (4+). Recurrent eDKA was diagnosed. Insulin infusion was re-started, causing resolution. The patient was treated with cefazolin and underwent surgical debridement of necrotic muscle.

The risk of eDKA with SGLT2i use is increased in patients with T1DM with decreased oral intake, surgery or trauma. Although the half-life of empagliflozin is 12 to 14 hours, persistent euglycemic DKA for 7 to 12 days from the last dose has been reported. Persistent glucosuria and ketonuria in this patient with serum glucose below the renal threshold confirmed recurrent eDKA.

eDKA may recur until 2 weeks from last dose of SGLT2i under certain conditions.