Euglycemic Diabetic Ketoacidosis Triggered by Sepsis in a Patient on Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor Therapy: A Case of Diagnostic and Therapeutic Challenges

Euglycemic diabetic ketoacidosis (EDKA) is an uncommon life-threatening condition increasingly recognized in patients treated with sodium-glucose co-transporter 2 (SGLT2) inhibitors. Its diagnosis is often delayed due to the absence of significant hyperglycemia. Sepsis can further complicate the clinical scenario, enhancing insulin resistance and promoting ketoacidosis. We report the case of a 69-year-old male with a history of diabetes mellitus managed with insulin, semaglutide, and empagliflozin, who presented with syncope, bradycardia, and gastrointestinal symptoms following antibiotic treatment for a lower extremity infection. Laboratory findings revealed high anion gap metabolic acidosis, lactic acidosis, mild hyperglycemia, and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Despite unremarkable imaging, suspicion for EDKA was heightened due to severe metabolic derangements and the patient's SGLT2 inhibitor use. Multidisciplinary management included aggressive fluid resuscitation, insulin therapy, empirical antibiotic coverage with vancomycin, and surgical debridement of a subsequently identified foot abscess. Clinical improvement paralleled the resolution of metabolic acidosis and bacteremia. This case highlights the critical need for early recognition of EDKA in patients on SGLT2 inhibitors, particularly in sepsis. Timely diagnosis, prompt management of underlying infections, and a multidisciplinary approach are essential for favorable outcomes.