We describe a case of acute poisoning in a 51-year-old female patient who presented to the Emergency Department with weakness, anxiety, dry mouth, bilateral mydriasis and lid drop. In differential diagnosis, botulism, Guillain-Barré syndrome and myasthenia gravis were considered, as well as cerebral haematoma because of a cranial injury a week before. Symptoms, which resolved within 12 h without any therapy, were instead related to the ingestion of lupin seeds.

Sodium-glucose cotransporter 2 inhibitors are a new second-line medication in the management of hyperglycemia in type 2 diabetes. These drugs can be associated with the development of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucose levels. This is a life-threatening clinical condition termed euglycemic DKA (euDKA), of which the diagnosis can be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes who presented to the Emergency Department with malaise, nausea and vomiting. Both patients had been taking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis, namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysis showed severe metabolic acidosis with increased anion gap, positive serum and urine ketones and normal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids, insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovered uneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterial blood gas analysis and serum ketones should lead to correct diagnosis of euDKA.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new second-line medication in the management of hyperglycemia in type 2 diabetes. These drugs can be associated with the development of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucose levels. This is a life-threatening clinical condition termed euglycemic DKA, of which the diagnosis can be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes who presented to the Emergency Department with malaise, nausea and vomiting. Both patients had been taking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis, namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysis showed severe metabolic acidosis with increased anion gap, positive serum and urine ketones and normal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids, insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovered uneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterial blood gas analysis and serum ketones should lead to correct diagnosis of euDKA.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, mainly localized in the stomach. Most GIST derive from mutations in tyrosine kinase receptors (KIT) or platelet-derived growth factor receptor-α (PDGFRA). GISTs are rarely associated with paraneoplastic hypoglycemia caused by non-β-cells tumor. This syndrome, defined non-islet cell tumor hypoglycemia (NICTH), arises from excess tumor production of insulin-like growth factor. We describe a 67-year-old female with severe NICTH secondary to an advanced and metastatic GIST.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new second-line medication in themanagement of hyperglycemia in type 2 diabetes. These drugs can be associated with thedevelopment of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucoselevels. This is a life-threatening clinical condition termed euglycemic DKA, of which the diagnosiscan be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes whopresented to the Emergency Department with malaise, nausea and vomiting. Both patients had beentaking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis,namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysisshowed severe metabolic acidosis with increased anion gap, positive serum and urine ketones andnormal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids,insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovereduneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterialblood gas analysis and serum ketones should lead to correct diagnosis of euDKA.