Latent autoimmune diabetes in adults (LADA) is a type of slow-onset, immune-mediated insulin deficiency involving progressive destruction of beta-cell function. Despite sharing some similarities with both type 1 and type 2 diabetes, LADA is a separate entity that should be given equal attention as patients with this condition are subject to severe complications and preventable hospitalizations without proper medical management if not diagnosed in a timely manner. Herein, we describe the case of a 45-year-old Hispanic female with a past medical history of presumed noninsulin-dependent type 2 diabetes managed with metformin for six years who presented with fatigue, dry cough, and intermittent presyncope for one week. Laboratory data revealed evidence of diabetic ketoacidosis. She also tested positive for coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although her respiratory status was stable and did not require treatment for COVID-19, she required high doses of insulin to normalize hyperglycemia and spent two days in the intensive care unit (ICU). Further evaluation revealed positive islet autoantibodies and decreased C-peptide levels, leading to a diagnosis of LADA. SARS-CoV-2 has been shown to enter islet cells via the angiotensin-converting enzyme-2 (ACE2), causing damage and inducing acute diabetes and associated complications, including ketoacidosis. It is conceivable that this patient had acute worsening of her diabetes through this mechanism. Recognition of this association may contribute to the timely diagnosis of LADA and prevention of medical complications due to inappropriate diabetes therapy.
This is a case of a 65-year-old female with a past medical history of type 2 diabetes mellitus (DM) and hypothyroidism who presented with a five-day history of shortness of breath, dry cough, and fatigue. Shortness of breath was exertional, and cough was intermittent. She had no exposure to COVID-19 infection. During the presentation, the patient required supplemental oxygen up to 6 liters per minute (L/m) and was tachypneic and tachycardic. Initial computed tomography (CT) of the chest revealed bilateral parenchymal disease compatible with COVID-19 pneumonia, however, the patient's COVID-19 polymerase chain reaction (PCR) test was persistently negative. Despite being treated for COVID-19 pneumonia, the patients' oxygen requirement increased, leading to the requirement of non-invasive positive pressure ventilation (BiPAP -bilevel positive airway pressure). The pulmonologist initiated a workup for possible underlying interstitial lung disease (ILD). Anti-glycyl transfer RNA (anti-EJ) antibody was positive on two occasions. The patient was started on pulse dose steroid and long-term steroid taper. The patient responded very well to the steroid and was later able to wean off the oxygen to room air. High-resolution CT which was done 3 months after the hospital stay revealed features suggestive of non-specific interstitial pneumonia (NSIP). Anti-synthetase syndrome is a rare but treatable etiology of ILD and should always be considered as a differential during workups.
Clinical trials of the messenger ribonucleic acid (mRNA)-1273 vaccine developed by Moderna proved excellent safety and efficacy for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) prevention. However, the Centers for Disease Control and Prevention (CDC) has been investigating cases of myocarditis and pericarditis reported in the Vaccine Adverse Event Reporting System (VAERS) database. Currently, the CDC is reporting rates of 40.6 cases per million after second doses of mRNA vaccines administered to males 30 years or younger. Notably, the initial vaccine trials consisted of a limited number of adolescents and young adults; therefore, they were likely not powered to detect this rare potential side effect. We present a case of transient myopericarditis occurring in a young and healthy patient within 48 h of his second vaccination dose. Although a definitive causal relationship has yet to be determined, we came to this correlation because of the temporal association seen in our patient, secondary to the second dose of vaccination. Furthermore, we also suspect an autoimmune mechanism as the cause of cardiac injury, augmented by the increased vaccine reactogenicity seen in younger patients.
Figure 1. EGD (a and b) and barium esophagram (c) findings.
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