Life-Threatening Metformin-Induced Lactic Acidosis Associated With Euglycemic Ketoacidosis and Acute Multiorgan Dysfunction: A Case Report

Abstract

Metformin-associated lactic acidosis (MALA) is a rare but life-threatening complication of metformin therapy. We present a case of a 63-year-old female with type 2 diabetes mellitus (on metformin and insulin) who developed severe lactic acidosis, euglycemic diabetic ketoacidosis (DKA), and acute kidney injury (AKI) following a three-day history of gastrointestinal symptoms. Despite initial stabilization efforts, the patient deteriorated into refractory shock and cardiac arrest, requiring intensive care unit (ICU) admission, continuous venovenous hemodiafiltration (CVVHD), vasopressor support, and mechanical ventilation. Serial arterial blood gas (ABG) analyses demonstrated profound metabolic acidosis (pH 6.77, lactate 20 mmol/L) with gradual normalization following CVVHD. The patient recovered fully, highlighting the importance of early recognition and aggressive management of MALA, including renal replacement therapy (RRT), in critically ill patients.

Keywords: acute renal injury; cardiac arrest outcome; continuous venovenous hemodialysis (cvvhd); diabetic ketoacidosis (dka); metformin associated gastrointestinal intolerance; metformin induced lactic acidosis; refractory lactic acidosis; refractory metabolic acidosis.

Figure 1. CT Abdomen with Contrast

Pancreas is normal in size with normal shape

Figure 2. CT Abdomen with Contrast

No active intestinal ischemia

Figure 3. CT Abdomen with Contrast

No intestinal ischemia

Figure 4. Chest X-Ray

The chest X-ray revealed that the endotracheal tube was positioned low in the right main bronchus, necessitating adjustment, while the left costophrenic angle was obscured by the cardiac shadow. No airspace opacities or pneumothorax were identified.