Clinical Mysteries • Endocrinology
The DKA With “Normal” Sugar
The presentation
A diabetic patient had vomiting, tachypnoea and high anion-gap acidosis, but glucose was only mildly elevated.
The first explanation was plausible, but the pattern did not fully fit. A deliberate second look focused on physiology, medication/exposure history, serial observations and the clue that the initial diagnosis could not explain.
The turn
Ketones, acidosis and SGLT2-inhibitor exposure solved the contradiction.
Diagnosis
Euglycaemic DKA
Why this case matters
Do not exclude DKA because glucose is below the classic threshold.
Take-home message: When the clinical course contradicts the working diagnosis, stop escalating the same treatment and rebuild the problem from first principles.