Case Presentation: We report a case of a 35-year-old pregnant female with a history of type 2 diabetes complaint with only dulaglutide but not insulin, hypertension, and hyperlipidemia who presented with a two-day history of chills, shoulder pain, and reduced range of motion. She had a history of chronic left shoulder pain managed with intra-articular corticosteroid injections, and imaging showed no evidence of fracture. The patient was admitted for septic arthritis of the left shoulder. During her hospital stay, she developed an elevated anion gap metabolic acidosis (pH: 7.30, bicarbonate: 11.8, anion gap: 16) with small elevation in blood glucose. She was positive for ketonuria and glucosuria. Upon admission she deteriorated and was transferred to the ICU for management of EDKA and initiated on an insulin drip, leading to the resolution of her anion gap and bringing her out of ketoacidosis.
Discussion: Euglycemic diabetic ketoacidosis (EDKA) is a life-threatening yet under-recognized complication of diabetes, observed in both type 1 and type 2 diabetes. EDKA is characterized by metabolic acidosis and ketonemia in the absence of significant hyperglycemia. The absence of ketoacisosis-related complications may delay diagnosis, leading to severe consequences. Common precipitating factors include medication use (e.g., SGLT2 inhibitors), acute illnesses such as sepsis or trauma, and pregnancy.
Conclusions: This case underscores the importance of recognizing EDKA, particularly in the context of rising GLP-1 receptor agonist use for diabetes and weight management. EDKA remains a rare but serious condition, and timely identification and management are critical to preventing morbidity. This report also emphasizes the need for heightened clinical suspicion of EDKA in pregnant or septic patients with diabetes, even when blood glucose levels do not suggest DKA.
