Sodium-glucose cotransporter-2 (SGLT2) inhibitor-induced euglycemic diabetic ketoacidosis complicating the perioperative management of a patient with type 2 diabetes mellitus (T2DM) and Fournier’s gangrene: A case report

INTRODUCTION: Sodium glucose cotransporter-2 inhibitors (SGLT2) are an increasingly administered class of medication used to lower blood glucose levels in patients with type 2 diabetes mellitus. Diabetic ketoacidosis (DKA) and Fournier’s gangrene are rare, but potentially catastrophic side effects of SGLT2 inhibitors. This manuscript reports a case of both DKA and Fournier’s gangrene in the context of SGLT2 inhibitor use. PRESENTATION OF CASE: A 51-year-old morbidly obese man with hypertension and poorly controlled Type 2 Diabetes Mellitus presented to the emergency department with a clinical presentation consistent with Fournier’s gangrene. He was promptly taken to the operating room by the urology team where he had extensive debridement of the perineum and abdomen. Intra-operatively he was found to have DKA, which was managed appropriately. The acidosis and Fournier’s gangrene were deemed a likely side effect of SGLT2 inhibitor use. After a thirty-day hospital admission, the patient was discharged to a rehabilitation facility where he is progressing well. His SGLT2 inhibitor was discontinued upon admission to hospital. DISCUSSION: Perioperative providers should have a high index of suspicion for diabetic ketoacidosis (DKA) and Fournier’s gangrene in patients prescribed SGLT2 inhibitors. Prompt treatment of DKA through correction of underlying triggers, aggressive fluid resuscitation, insulin to close the anion gap, and appropriate potassium repletion is vital to optimize patient outcomes. CONCLUSION: The use of SGLT2 inhibitors among surgical populations is increasing. This case highlights the importance of being aware of the mechanism and side effects of SGLT2 inhibitors, and the management of DKA.