S5187 Invasive Gastric Mucormycosis Following SGLT2-Inhibitor-Induced Euglycemic DKA in a Patient With Poorly Controlled Diabetes Mellitus

Introduction: Mucormycosis is a rare but potentially fatal fungal infection primarily affecting immunocompromised individuals. Gastrointestinal involvement, especially gastric mucormycosis, is uncommon and often diagnosed late due to nonspecific symptoms. Euglycemic diabetic ketoacidosis (DKA), a recognized complication of sodium-glucose cotransporter 2 (SGLT2) inhibitors, may exacerbate immunosuppression in poorly controlled diabetics. We report a case of invasive gastric mucormycosis in a patient with uncontrolled type 2 diabetes mellitus (T2DM) following inappropriate substitution of insulin with an SGLT2 inhibitor. Case Description/Methods: A 54-year-old man with poorly controlled T2DM presented with severe epigastric pain and vomiting following recent hospitalization for euglycemic DKA after cessation of insulin therapy and initiation of an SGLT2 inhibitor. Esophagogastroduodenoscopy revealed 2 necrotic gastric ulcers, 1 subcardial and another 5–6 cm in the mid-gastric body, with retained food suggestive of gastroparesis. Biopsies and fungal culture confirmed heavy growth of Mucor species, with broad, non-septate, right-angle branching hyphae. He was treated with oral posaconazole and re-initiation of insulin. Despite treatment, symptoms recurred, requiring multiple hospitalizations. Discussion: This case emphasizes 2 key considerations: (1) the risk of euglycemic DKA from SGLT2 inhibitors in uncontrolled diabetes, and (2) the importance of including invasive fungal infections in the differential for necrotic gastric ulcers in immunocompromised patients. Early biopsy and fungal culture are essential for diagnosis. Recurrence may occur despite antifungal therapy if metabolic derangements persist. Clinicians should maintain a high index of suspicion for mucormycosis in diabetic patients with atypical gastric ulcers, especially after SGLT2 inhibitor use. Prompt diagnosis and metabolic control are critical for improving outcomes.