Severe Euglycemic diabetic ketoacidosis with mixed Acid–Base disorder following acetazolamide initiation in type 2 diabetes: a case report and review of literature

Euglycemic diabetic ketoacidosis (euDKA) is an increasingly recognized complication of sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy, characterized by severe metabolic acidosis with near-normal blood glucose levels. We report a rare case of a 45-year-old woman with type 2 diabetes mellitus who presented with severe euDKA (pH 6.85, glucose 170 mg/dl) following initiation of acetazolamide for glaucoma management. Clinical evaluation revealed profound metabolic acidosis with bicarbonate 1.5 mmol/l and anion gap 27 mmol/l. Delta ratio calculation (0.64) revealed a mixed high anion gap and normal anion gap metabolic acidosis, indicating dual pathophysiology: ketoacid accumulation from euDKA and acetazolamide-induced renal bicarbonate wasting. Immediate acetazolamide discontinuation combined with aggressive fluid resuscitation, insulin infusion, and sodium bicarbonate resulted in complete metabolic correction by Day 3 without hemodialysis. To our knowledge, this rare combination of SGLT2 inhibitor use and acetazolamide underscores the need for careful medication reconciliation and multidisciplinary communication in diabetic patients to prevent complications.