Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis Presenting With Severe Abdominal Pain Mimicking Acute Peritonitis

Euglycemic diabetic keto acidosis (eu-DKA) is a rare but life-threatening metabolic complication associated with sodium-glucose cotransporter-2 (SGLT-2) inhibitor therapy, especially in the setting of extreme physical stress. Due to no apparent hyperglycemia, the significant risk of delayed diagnosis or misdiagnosis exists within patients. Herein, we report a novel case of dapagliflozin-associated eu-DKA with unusual presentation. A 57-year-old female with a six-year history of type 2 diabetes mellitus (DM), for which metformin and dapagliflozin were prescribed, developed severe abdominal pain and signs of acute peritonitis without obvious hyperglycemia after distal pancreatectomy. Based on CT scan and laboratory studies, gastrointestinal tract perforation was suspected but was excluded during laparotomy. Severe metabolic acidosis and strong positive urine ketone indicated diabetic keto acidosis. The patient recovered after active therapy with an intravenous insulin infusion, antibiotics and correction of hypotension, electrolyte imbalance and acidosis. This case provides a new reference for clinicians and surgeons to be concerned with eu-DKA with severe abdominal pain as the main symptom.