SUN-181 Case Report: Rare Complication of SGLT2 Inhibitors Can Occur Only 10 Days after Starting the Medication

Introduction: Fournier’s gangrene is an extremely rare infection that can occur in diabetic patients. The FDA recently issued a warning about patients taking sodium-glucose cotransporter-2 inhibitors stating that these patients are liable to develop Fournier gangrene. This complication usually occurs few months after starting the medication. Up to our knowledge, total 12 cases have been reported in literature from May 2013 to May 2018. We report another case of Fournier gangrene associated with the use of empagliflozin, however our case is unique as the presentation was only 10 days after starting the medication. Case report:We present a 57 years old Caucasian male with past medical history of uncontrolled type 2 diabetes diagnosed around 10 years ago and complicated by peripheral neuropathy, hashimoto’s hypothyroidism and morbid obesity who was following as outpatient with an endocrinologist. His hemoglobin A1C has been uncontrolled despite being on glipizide 10 mg BID, metformin 1gm BID and linagliptin 5mg daily so decision was made to start empagliflozin. After 10 days, patient complained of severe left groin pain for which he was initially treated as cellulitis in an outpatient facility however no improvement was noticed. He went to the ED. On physical examination, his weight 192 kilograms with BMI of 62.76kg/m(2), he was afebrile and vitally stable. Perineal examination revealed a grossly swollen and indurated right scrotum with tender spermatic cord, epididymis and testicles. There was associated bilateral inguinal lymphadenopathy. CT abdomen and pelvis showed Fournier gangrene so patient was transferred to our facility for surgical intervention. We were consulted after surgical debridement to help inpatient management of diabetes. Empagliflozin was discontinued upon admission. Upon further questioning, patient denied any similar condition in the past and prior history of genital or urinary infections. Discussion:Several infections can occur in patient with uncontrolled diabetes including Fournier gangrene and other life threatening infection. SGLT2 inhibitors are known to increase risk of genitourinary infection. However given the recent FDA warning regarding the new side of effect of SGLT2 inhibitors, physician should be aware that Fournier gangrene can occur in diabetic patients especially the ones with potential risk of genital infection. As per the FDA report, from the 12 cases of Fournier gangrene in patients using SGLT2 inhibitors, 7 were men and 5 were women and it developed within several months after starting the medication. They were divided into 7 men and 5 women. All of them were hospitalized and required surgery similar to our patient. Conclusion: SGLT2 inhibitors has been commonly associated with urinary tract infection, however risk factors including diabetes, obesity may increase the risk of potentially more severe infections such as Fournier's gangrene.