Euglycemic diabetic ketoacidosis: A missed diagnosis

Table 1 Precipitating causes for euglycemic diabetic ketoacidosis and their mechanisms

Risk factors	Pathophysiology
Infection	Insulin resistance due to counterregulatory hormones (adrenaline, glucagon, etc.), increased peripheral glucose utilization, decreased intake (nausea, vomiting)
Surgery	Perioperative fasting, gastrointestinal surgery has increased incidence as fasting is prolonged and/or gut absorption is slow
Fasting	Decreased glycogen stores, increased risk with SGLT-2 inhibitors and type 1 DM
Alcohol intake	Deceased carbohydrate intake, osmotic diuresis, increased ketogenesis (beta hydroxybutyrate) due to altered NADH/NAD ratio, increased risk in patients on SGLT-2 inhibitors
Acute vascular events (ACS or stroke)	Increased counterregulatory hormones, decreased oral intake
Trauma	Decreased oral intake, increased counterregulatory hormone, blood glucose dilution by large fluid shifts during resuscitation
Prolonged physical activity or exercise	Increased counterregulatory hormones, increased peripheral glucose utilization, decreased carbohydrate intake

ACS: Acute coronary syndrome; DM: Diabetes mellitus; NAD: Nicotinamide adenine dinucleotide; NADH: Nicotinamide adenine dinucleotide hydrogen; SGLT2: Sodium/glucose cotransporter-2.