Case Report: Normoglycemic Diabetic Ketoacidosis Post Gastric Botulinum Toxin Injection for Weight Loss

Dr. Riyadh Hammamy, Dr. Khalid Farooqui, Dr. Mohamed Shariff, Dr.Wissam Ghadban

True normoglycemic diabetic ketoacidosis (when the blood glucose is below 200 mg/dl) is relatively uncommon and in type 2 diabetes mellitus (T2DM) can be caused by starvation due to various reason, like prolonged fasting, malnutrition, persistent vomiting,post bariatric gastric surgery, chronic alcohol intake, Atkins diet, pregnancy and eating disorder. It is also encountered following the endoscopic procedure using gastric botulinum toxin injection as part of non-surgical bariatric procedure for weight loss in obese people. This procedure can be unsafe in diabetic patients as it is difficult to achieve glycemic control due to unpredicted gastric emptying time and the ability of the individual to have adequate nutrition. We report a case with normoglycemic diabetic ketoacidosis precipitated by starvation post gastric botulinum toxin injection in a patient with T2DM. On presentation patient was acidotic with positive blood ketones and a blood glucose levels of 106 mg/dl, after correction of acidosis the patient was discharged. This case highlights the need to assess the acid-based status even with normal blood glucose levels, especially in those who have received a gastric botulinum toxin injection resulting in poor oral intake.