Introduction: Sarcoidosis is a systemic disorder with a wide range of manifestations. Due to systemic involvement, systemic steroids are most commonly used to improve symptoms and mortality, however, steroids have a significant side-effect profile. We present a case of euglycemic diabetic ketoacidosis in a patient with sarcoidosis treated with systemic steroids. 

 

Case Presentation: History: A 78-year-old female with a medical history of type II non-insulin dependent diabetes, and sarcoidosis with pulmonary and bilateral ocular involvement, presented with a complaint of abdominal pain and vomiting. Her medications included empagliflozin, metformin and sitagliptin for diabetes. The patient was recently initiated on high dose prednisone for the treatment of pulmonary and ocular sarcoidosis flare.

 

Physical exam: Unremarkable including abdominal exam

 

Lab tests: Sodium 130 mmol/L, potassium 4.4mmol/L, bicarbonate 13mmol/L, anion gap 22, BUN 53mg/dL, creatinine 1.1 mg/dL and glucose 232 mg/dL. 

 

Further workup revealed high beta-hydroxybutyrate 9.29 mmol/L, urinary ketones 80 mg/dl, and normal lactate.

 

Imaging: CT chest showed prominent bilateral perihilar regions and calcifications consistent with worsening of sarcoidosis.

 

Final Diagnosis:  Drug-induced Euglycemic Diabetic Ketoacidosis (EuDKA).

 

Management: DKA protocol was initiated. Prednisone and oral diabetic agents were discontinued, however, in two days she experienced worsening ocular symptoms, suspicious of ocular sarcoidosis flare. Steroids were reinitiated and glycemic control was tightened with insulin. Ocular symptoms were improved with the reintroduction of steroids. 

 

To our knowledge, this is the first case to be reported as EuDKA in the context of sarcoidosis who was taking systemic steroids. Although the use of SGLT2 inhibitors could have contributed to the development of EuDKA, the temporal association with initiation of steroid therapy, could not be dismissed. 

 

Outcome/Follow-up: Our patient highlights the therapeutic dilemma in the management of systemic sarcoidosis when patient developed an adverse event related to steroids. Ideally, short-term insulin therapy with discontinuation of the offending agent would be the cornerstone of management, however, this strategy added another layer of clinical complexity by worsening the sarcoidosis flare. Patient was eventually discharged on insulin with the lowest tolerable dose of steroid with close outpatient follow-up.