Euglycemic diabetic ketoacidosis associated with empagliflozin in patients hospitalized with acute pulmonary embolism

Euglycemic diabetic ketoacidosis (Eu-DKA) is a rare but life-threatening complication in diabetic patient treated with sodium-glucose cotransporter 2 inhibitors (SGLT2i). A 71-year-old diabetic female treated with empagliflozin presented to the ED with shortness of breath. Diagnosis of acute pulmonary embolism was confirmed initially. She was treated conservatively with subcutaneous enoxaparin 60 mg bidaily. and oxygen therapy.  Respiratory distress associated with anion gap — metabolic acidosis and ketosis developed on the following days however her blood glucose levels were always within normal limit. Clinical recovery was gained after stopping the drug, administering rehydration, and insulin drip. Complica-tion of DKA without hyperglycaemia should be consid-ered while evaluating ketoacidosis in diabetic patients treated with SGLT2i, particularly in critical illness cases.