MON-650 A Presentation of Euglycemic DKA Precipitated by Paraganglioma

Abstract Disclosure: R. Maini: None. J. Noel: None. G. O'Malley: None. Introduction: Patients with secretory pheochromocytomas and paragangliomas commonly present with secondary diabetes mellitus. Both impaired insulin secretion and increased insulin resistance have been implicated with the release of catecholamines. Clinical Case: A 53-year-old female with type 2 diabetes, hypothyroidism due to Hashimoto’s disease, and hypertension presented with abdominal pain and vomiting. The patient also reported episodic headaches, palpitations, and flushing, though these symptoms occurred only a few times a year. Due to insurance issues, she had stopped her diabetes regimen of Jardiance and Ozempic eight months prior. Over this time, her HbA1c increased from 7.3 to 12.1%. She was started on basal insulin three days prior to presentation. On admission, she experienced an asymptomatic episode of elevated blood pressure to 209/83. Initial laboratory findings showed a glucose level of 150 mg/dL, bicarbonate of 8.9 mEq/L, pH of 7.31, beta-hydroxybutyrate of 8.10 mmol/L, and anion gap of 21 mEq/L, meeting criteria for euglycemic diabetic ketoacidosis (DKA). CT abdomen/pelvis with contrast showed a 5.5 x 4.7 x 4.3 cm retroperitoneal mass abutting the uncinate process of the pancreas. Plasma normetanephrines and urine normetanephrines were both elevated to 1148 pg/ml and 2370 micrograms/24 hr, respectively. Plasma and urine metanephrines were normal, supporting the diagnosis of a paraganglioma. For management of the euglycemic DKA, the patient was treated with an insulin drip, intravenous fluids, and transitioned to basal insulin. She was discharged on Doxazosin 1 mg at bedtime for alpha blockade. Outpatient PET Dotatate scan showed an intensely somatostatin receptor-expressing, Krenning 4 soft tissue mass. Doxazosin was titrated to 2 mg twice a day, and Metoprolol XL 25 mg was added for beta blockade to optimize for surgery. Patient is undergoing surgical removal of paraganglioma. Conclusion: This is the first reported case documenting a presentation of euglycemic DKA triggered by a paraganglioma. The patient had discontinued her SGLT-2 inhibitor and had no other etiology for the disease trigger. Excessive normetanephrines can contribute to lipolysis and impaired pancreatic beta cell function, leading to euglycemic DKA. Presentation: Monday, July 14, 2025