Euglycemic diabetic ketoacidosis in a neurosurgical patient on empagliflozin: a case report

Background: Euglycemic diabetic ketoacidosis (EDKA) is a rare but serious complication linked to sodium-glucose cotransporter 2 inhibitor use. Cases of EDKA are increasingly being diagnosed during the perioperative period; however, owing to normal glucose levels, the condition is often overlooked or misattributed to other causes, such as surgical complications—particularly in patients undergoing neurosurgery.Case Report: We present a case of a man in his seventies with poorly controlled diabetes and recent empagliflozin use who developed EDKA following a craniectomy for drainage of an intracranial abscess, with postoperative symptoms mimicking those of an intracranial process. Despite mildly elevated glucose levels, a basic metabolic panel revealed high anion gap metabolic acidosis. Insulin and dextrose therapy was initiated, and the condition resolved within 24 hours. Conclusion: This case underscores the need for early recognition of EDKA, especially in neurosurgical settings, where many neurological symptoms of ketoacidosis can be misattributed to postoperative complications.