The Mystery of Acidosis

We present a case of 30-year-old female with past medical history of Type 2 DM, Thyroid nodule and asymptomatic cholelithiasis who presented to ED with abdominal pain, vomiting and sinus tachycardia of 120’s for past one day. She had generalized abdominal pain, not relieved by pain killers. Her lab test includes normal blood count, glucose 150mg/dl, anion gap of 20, metabolic acidosis. Her ultrasound abdomen showed cholelithiasis with no biliary sludge formation. Given her acidosis and severe abdominal pain she was started on Zosyn and underwent cholecystectomy. Her abdominal pain and sinus tachycardia did not resolve till day 3 of admission. Urine was positive for ketones. On chart review, it was found that she started taking sodium glucose transporter 2 inhibitor (SGLT-2 inhibitor), Canagliflozin. She was given IV fluids and insulin. She improved and her tachycardia resolved. Euglycemic acidosis is a rare phenomenon but frequently misdiagnosed. This case emphasizes on importance of side effects of oral glucose lowering agents. SGLT-2 inhibitors can cause lipolysis and ketosis while maintaining euglycemia. Prompt clinical judgement is needed to prevent misdiagnosis. Also, patients should be educated about aggravating factors like stress, dehydration or other severe illnesses.