Abstract Introduction Pulmonary embolism (PE) is an uncommon precipitator of diabetic ketoacidosis (DKA), with mortality as high as 27% in the first 24 hours in high-risk PE. Major guidelines recommend urgent systemic thrombolysis as first-line treatment for high-risk PE, while large-bore mechanical thrombectomy (LBMT) is emerging as an effective intervention. Case A 70-year-old female with a history of type 2 diabetes mellitus (T2DM), recent ischemic stroke, and segmental PE presented with altered mental status. On arrival, she was tachycardic at 127 bpm, and her blood pressure was 95/73 mmHg. Laboratory data showed DKA (glucose: 375 mg/dL, HCO3: 17 mEq/L, Anion Gap: 23 mEq/L, and betahydroxybutyrate 4 mmol/L). Despite aggressive volume resuscitation and resolution of DKA, she was persistently tachycardic, hypotensive, and hypoxemic. Further workup revealed a troponin of 0.5 ng/mL and BNP 897 pg/mL. Chest X-ray was unremarkable, and EKG showed ST depression in the inferolateral leads. A bedside point-of-care ultrasound (POCUS) showed a small right pleural effusion and a dilated right ventricle (RV) without McConnell’s sign. Computed tomography pulmonary angiogram (CTPA) evidenced a right greater than left main PE with RV strain, transthoracic echocardiogram (TTE) showed RV dilatation and severe dysfunction. She was treated as high-risk PE with an urgent LBMT. Patient’s hemodynamics improved after LBMT, and she was discharged on anticoagulation. A TTE repeated 1 month later showed resolution of RV dilatation and dysfunction. Discussion This case highlights PE as an underrecognized precipitant of DKA, especially in unresolved shock, and how a timely diagnosis via bedside POCUS and CTPA is essential to intervene early. While guidelines recommend systemic thrombolysis as first-line treatment for high-risk PE, there is limited applicability in real life scenarios, commonly due to relative or absolute contraindications. LBMT has emerged as a safe and effective intervention; a recent trial (PEERLESS) showed a lower rate of clinical deterioration and ICU stay compared with catheter-directed thrombolysis. Further trials (PEERLESS II) are in the making, comparing LBMT with anticoagulation. In our patient, LBMT as first-line treatment led to hemodynamic stabilization and gradual neurologic recovery, aligning with emerging data supporting LBMT for intermediate to high-risk PE. This case highlights the importance of considering PE as a precipitant of DKA in elderly patients, especially when hemodynamic status does not improve as expected. Additionally, LBMT as a first-line treatment for intermediate to high-risk pulmonary embolism arises as an attractive alternative. This abstract is funded by: None
Romero et al. (Fri,) studied this question.