(645) A Case of Euglycemic Diabetic Ketoacidosis in a COVID-19-Positive Pregnant Patient

Introduction: Euglycemic diabetic ketoacidosis (DKA) is a rare but known complication in pregnancy. Since the emergence of the novel SARS-CoV-2 virus we have witnessed many cases of unusual and severe DKA associated with this infection.

Description: This is the case of a 45-year-old female, pregnant at 37 weeks, known with gestational diabetes (GDMA1) who presented with fever, cough, body aches, three-day history of intractable nausea and vomiting. The patient sought medical attention for intractable nausea and vomiting. Her medications were prenatal vitamins. On admission her vitals were significant for a heart rate 102 beats/minute. Physical exam was unremarkable except for dry mucosal membranes and a gravid uterus appropriate for gestational age.
Her chemistry revealed a sodium of 134 mEq/L, a potassium of 4.1 mEq/L, a chloride of 111 mEq/L, a bicarbonate of 12 mEq/L, a BUN of 6mg/dL, and a creatinine of 0.7mg/dL. Her anion gap was 17 mEq/L. Her initial blood glucose was 82mg/dL. Her arterial blood gas revealed a pH of 7.27, a PaCO2 of 14 kPa, a PaO2 of 123, a bicarbonate of 6.1mmol/L, with a base deficit of -18mmol/L. She had positive ketones in her blood and urine. Lactic acid level was 1.2 mmol/L. She also had a positive SARS-CoV-2 test.
In the emergency department chest radiograph and cardiac computed tomography angiography with pulmonary embolism protocol were performed. These were negative for any acute pathology. A fetal Non-stress Test (NST) was reactive.
The patient was given two ampoules of sodium bicarbonate and initially hydrated with isotonic fluids. She was given antiemetics and broad spectrum antibiotics. She was admitted to the Intensive Care Unit given her SARS-CoV-2 positivity and was observed. Her acidosis worsened, and a diagnosis of Euglycemic DKA was suspected. The patient was placed on standard diabetic ketoacidosis protocol with an insulin drip and Dextrose 5% in Water. There was a marked improvement in her overall clinical picture and a resolution of her anion gapped metabolic acidosis within 12 hours of treatment. The patient recovered unremarkably and was discharged home on hospital day 5.

Discussion: This case shows the necessity of recognizing this lesser encountered clinical scenario. With the correct treatment resolution can rapidly be achieved.