Unmasking Euglycemic Diabetic Ketoacidosis: The Interplay of Pregnancy, Sepsis, and Glucagon-Like Peptide 1 Analog.

Euglycemic diabetic ketoacidosis (EDKA) is a life-threatening, yet under-recognized, complication of type 1 and type 2 diabetes. EDKA is characterized by metabolic acidosis and ketonemia in the absence of significant hyperglycemia. The absence of ketoacidosis-related complications may delay diagnosis, leading to severe consequences. Common precipitating factors include medication use (e.g., sodium-glucose cotransporter 2 inhibitors), acute illnesses (e.g., sepsis), trauma, and pregnancy. We report the case of a 35-year-old pregnant female with a history of type 2 diabetes, hypertension, and hyperlipidemia who presented with a two-day history of chills, shoulder pain, and reduced range of motion. The patient was compliant with dulaglutide, but not insulin. She had a history of chronic left shoulder pain managed with intraarticular 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 with a small elevation in her blood glucose. She tested positive for ketonuria and glucosuria. Upon admission, she deteriorated and was transferred to the intensive care unit for the management of EDKA. An insulin drip was initiated, leading to the resolution of her anion gap and resolving the ketoacidosis. This case underscores the importance of recognizing EDKA, particularly in the context of rising glucagon-like peptide 1 receptor agonist use for diabetes and weight management. EDKA remains a rare but serious condition, and timely identification and management are critical in 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 diabetic ketoacidosis.