COVID-19 and Diabetic Ketoacidosis: Report of Eight Cases

Abstract

To describe the clinical characteristics and outcome of hospitalized COVID-19 patients with diabetic ketoacidosis (DKA). MethodsWe report eight cases of diabetic ketoacidosis in COVID-19 who presented to our institution in New Jersey, USA. COVID-19 was diagnosed by nasopharyngeal swab reverse transcription polymerase chain reaction (RT-PCR). The patients' electronic medical records were reviewed. Data on patients' age, sex, ethnicity, laboratory values, glycosylated hemoglobin level, oral antihyperglycemic agents (OHAs), insulin, and clinical outcomes were collected. ResultsThe median age of the patient was 42.5 years, and seven were males and one was female. Out of eight patients, five had type 2 diabetes mellitus (DM), two had undiagnosed DM, and one had type 1 DM. Median value of initial glucose on presentation was 454 mg/dL. Median value of HbA1c on presentation was 11.4% and of anion gap was 26.5 mEq/L. Four patients had large ketonemia, one patient had moderate ketonemia, and three patients had small ketonemia. All the patients were started on standard treatment protocol for DKA with intravenous fluids and IV insulin infusion. Acute kidney injury (AKI) was seen in four patients, and one patient required renal replacement therapy. Out of eight patients, three required mechanical ventilation, and the same three patients died. ConclusionOur case series shows that COVID-19 infection can precipitate DKA in patients with known diabetes mellitus patients or as a first manifestation in undiagnosed DM patients; COVID-19 with DKA is associated with substantial mortality. Further studies are needed to characterize poor risk factors associated with mortality in these patients.

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

“…pH of < 7) has been identified as an important predictor of mortality in patients with DKA and COVID-19 compared to those who survived ( p = 0.047) [ 90 , 91 ]. Very high uncontrolled random blood glucose level (> 1000 mg/dl) was the other biochemical parameter at presentation that differed significantly between the survival and death groups in DKA patients infected with SARS-CoV-2 ( p = 0.048); a finding suggested in previous studies [ 91 , 95 , 96 ] and in contradiction with data from case reports demonstrating death in DKA cases during COVID-19 infection when their blood glucose levels were kept at < 500 mg/dl [ 27 , 59 , 63 ]. Moreover, increasing age in combination with male gender and BMI ≥ 30 might denote seriously sick patients who can potentially have more morbidity and propensity to die.…”

“…Among the included studies, 11 reported DKA and COVID-19 in children [ 8 , 11 , 22 , 30 , 34 , 44 , 45 , 56 , 61 , 66 , 72 ], 56 reported DKA and COVID-19 in adults [ 9 , 10 , 12 – 21 , 23 , 25 – 29 , 31 – 33 , 35 – 43 , 46 – 55 , 57 – 60 , 62 – 65 , 67 – 71 , 73 – 75 ], and only 1 study reported DKA and COVID-19 in both children and adults [ 24 ]. There were 54 case report [ 8 – 12 , 14 , 16 , 17 , 19 – 23 , 25 – 27 , 29 – 42 , 44 – 51 , 53 – 58 , 60 , 61 , 64 , 66 , 67 , 69 , 71 , 72 , 74 , 75 ], 10 case series [ 13 , 15 , 28 , 43 , 58 , 59 , 62 , 63 , 70 , 73 ...…”

“…The median or mean patient age ranged from < 1 years to 66 years across studies. There was an increased male predominance in DKA patients diagnosed with SARS-CoV-2 in most of the studies [n = 373, 58.4%] [ 9 – 13 , 15 – 17 , 19 , 20 , 23 , 25 , 26 , 31 – 33 , 36 , 37 , 39 , 45 , 47 , 50 – 52 , 55 – 58 , 60 – 64 , 67 – 69 , 74 , 75 ] and majority of the patients belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity [ 14 – 16 , 18 , 19 , 21 , 24 , 27 , 28 , 44 – 46 , 54 , 57 , 58 , 62 , 63 , 65 , 68 , 75 ]. The median BMI for all included patients was 27.3 kg/m 2 [interquartile range (IQR) 24.8–30.6 kg/m 2 ].…”

Assessment of Insulin Infusion Requirements in COVID-19-Infected Patients With Diabetic Ketoacidosis

“…Disease severity and disease progression were also worse in the COVID-19 cohort as represented by vasopressor data, dialysis use, and intubation rates. Mechanically ventilated patients with COVID-19 and DKA have been shown to have worse outcomes while patients with diabetes have also been shown to have longer lengths of stay compared to patients without diabetes according to previously published case reports ( 19 ).…”

COVID-19 Viral Infection Presenting with Diabetic Ketoacidosis, Hyperosmolar Hyperglycemic Syndrome, or Mixed Hyperglycemic Crisis: A Case Series

“…7.5 million adults aged 18 and older were unaware of their diagnosis, accounting for 2.8% of all adults in the United States and 21.4% of all persons with diabetes. 4 DKA is the most prevalent hyperglycemic crisis, which also includes HHS and the overlap syndrome of DKA and HHS, known as hyperosmolar ketoacidosis. DKA occurs when there is a relative or absolute insulin deficiency, resulting in decreased glucose utilization and unhindered lipolysis, leading to higher ketone body formation and eventually metabolic acidosis.…”