317: Euglycemic DKA in a COVID-19 Patient

Abstract

INTRODUCTION: SARS-CoV-2 (COVID-19) infection has impacted millions worldwide Presentation varies from asymptomatic carriers to fulminant acute respiratory distress syndrome (ARDS) Diabetes mellitus (DM) increases risk of severe illness and hyperglycemia is associated with higher morbidity and mortality in critically ill COVID-19 patients We present a case of anion gap euglycemic diabetic ketoacidosis (EuDKA) in a critically ill patient with COVID-19 infection METHODS: A 50-year-old male with DM, treated with an SGLT2 inhibitor, was positive for COVID-19 requiring vasopressor support and intubation for ARDS Admission labs revealed glucose 123 mg/dL, A1C 8 6%, sodium (Na) 134 mmol/L, potassium (K) 3 7 mmol/L, chloride (Cl) 98 mmol/L, bicarbonate (HCO3) 23 mmol/L, and normal creatinine SGLT2 therapy was stopped, and sliding scale insulin started By day 3, he developed acute kidney injury (Scr 1 69 mg/dL) with anion gap (AG) metabolic acidosis His Na was 133 mmol/L, K 3 8mmol/L, Cl 98 mmol/L, and HCO3 17 mmol/L Arterial blood gas revealed pH 7 14 with normal lactate level A beta-hydroxybutyrate (BHB) level was 2 9 mmol/L, but Propofol Infusion Syndrome (PRIS) was considered as etiology of the anion gap acidosis given high propofol requirements Propofol was stopped and bicarbonate infusion was initiated but acidosis persisted: repeat studies showed Na 148mmol/L, K 4 6mmol/L, Cl 108 mmol/L, HCO3 16mmol/L, glucose 210 mg/dL and pH 7 17 with AG 24 Repeat BHB was 6 9 mmol/L EuDKA was diagnosed, an insulin infusion was started and within 24 hours, his acidosis resolved RESULTS: EuDKA is a rare entity and, to our knowledge, has not been reported in a patient with COVID-19 The hallmark of EuDKA is an unexplained anion gap metabolic acidosis, with ketonemia, and blood glucose generally less than 200-250 mg/dl (7) It has primarily been reported in patients using SGLT2 inhibitors and starvation Absence of significant hyperglycemia and initial BHB level of less than 3 may have delayed recognition of the underlying etiology of acidosis in this case Physicians must remain cognizant of this presentation in order to begin appropriate therapy and decrease in-hospital morbidity and mortality