Late-Onset Euglycemic Diabetic Ketoacidosis in a Patient With Massive Stroke Requiring Decompressive Craniectomy: A Case Report

Euglycemic diabetic ketoacidosis (DKA) is a well-recognized adverse effect associated with the use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. Early recognition of this medical emergency and timely intervention can prevent the notorious consequences of this serious complication. However, this form of DKA can easily be masqueraded by normal serum glucose levels. This article describes a 49-year-old man diagnosed with type 2 diabetes mellitus (DM) on dapagliflozin who presented with a large right-sided middle cerebral artery (MCA) stroke complicated by euglycemic DKA, developed 72 hours after stopping the drug. This case is unique considering that dapagliflozin's half-life is only 12.9 hours, and the body completely eliminates it within 72 hours. But our patient developed DKA features after the elimination window. Hence, this case highlights the importance to consider euglycemic DKA in the presence of ketonemia and metabolic acidosis in a patient who is a chronic SGLT-2 inhibitor user even if the drug was discontinued several days before the patient's presentation.