Cardiogenic shock associated with stress-induced cardiomyopathy in the setting of diabetic ketoacidosis initially suspected to be septic shock: a case report

Background: Shock associated with diabetic ketoacidosis (DKA) is commonly hypovolemic or distributive in nature, reflecting its underlying pathophysiology and precipitating factors. However, in rare cases, DKA can precipitate stress-induced cardiomyopathy, which may lead to cardiogenic shock. In addition, DKA causes metabolic derangements, increasing the risk of additional cardiac complications. Case Description: A 30-year-old woman with no known past medical history presented with acute onset of fever and altered mental status. Laboratory evaluation demonstrated hyperglycemia, metabolic acidosis, elevated anion gap, increased beta-hydroxybutyrate, and elevated lactate. Diabetic ketoacidosis and hyperosmolar hyperglycemic state (DKA/HHS) overlap was diagnosed, and possible sepsis was also considered. Standard management was initiated. However, the patient continued to require high-dose vasopressors. Further evaluation revealed diffuse ST-segment elevations on electrocardiography and a reduced left ventricular ejection fraction (LVEF) with mid-distal anteroseptal and apical hypokinesis on transthoracic echocardiography. Right and left heart catheterization demonstrated low-output cardiogenic shock with biventricular failure, requiring intra-aortic balloon pump (IABP). With hemodynamic stabilization and treatment of DKA/HHS, IABP was successfully weaned off. Serial echocardiography demonstrated normalization of LVEF, which was consistent with stress-induced cardiomyopathy. Conclusions: Shock in the setting of DKA is not necessarily hypovolemic or distributive. In cases of persistent shock in DKA, clinicians should pursue early cardiac evaluation and consider mechanical circulatory support for possible cardiogenic shock due to stress-induced cardiomyopathy. Early hemodynamic stabilization alongside rigorous treatment of DKA is important for favorable outcomes.