Hyperglycemic Emergencies Associated With COVID-19 Vaccination: A Case Series and Discussion

Abstract

Context Hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) and new-onset diabetes mellitus (DM) have been reported in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Hyperglycemia is a predictor of poor prognosis in COVID-19 disease. Objectives The objective of this work is to describe a case series of HHS and/or DKA likely triggered by the COVID-19 vaccine. The aim is to alert physicians of the potential hyperglycemic complications from the COVID-19 vaccination and to provide further insight into the underlying mechanism of the bidirectional relationship between SARS-CoV-2 and DM. Case description All 3 patients developed HHS and/or DKA within 2-10 days of the COVID-19 vaccination. PCR testing for SARS-CoV-2 was negative and other clinical precipitating factors were excluded. Two patients had a history of type 2 DM (T2DM) with pre-admission HbA1c levels of 7.0-7.5% while one patient was newly diagnosed with T2DM during the hospitalization. They were each treated with insulin infusion and were discharged on subcutaneous insulin therapy. Due to the rapid resolution of the hyperglycemia, insulin was discontinued in all patients within 8 weeks and they remain well-controlled on oral DM medications. Conclusion Severe hyperglycemia including HHS and DKA may be triggered by COVID-19 vaccination. Early evaluation and screening of patients with hyperglycemic symptoms after COVID-19 vaccination is recommended. The vaccine-induced hyperglycemia may provide further insight into the underlying pathogenesis caused by the SARS-CoV-2 infection itself. The underlying robust inflammatory response and “cytokine storm” may be the primary precipitant.

Diabetic ketoacidosis (DKA) in type 1 diabetes mellitus (T1DM) temporally related to COVID-19 vaccination

“…Abu-Rumaileh et al [ 18 ] reported one patient of HHS, whereas Edwards et al [ 19 ] and Lee et al [ 20 ] each reported three patients of hyperglycemic emergencies respectively. These patients had preexisting or newly diagnosed type 2 diabetes mellitus (T2DM), were older at presentation, had one or more features of metabolic syndrome and one patient had cardiovascular complications.…”

“…Notably, all the patients reported by Abu-Rumaileh et al [ 18 ] and Lee et al [ 20 ] could be transitioned to oral hypoglycemic agents on outpatient follow-up after the initial intravenous fluid and insulin therapy. C-peptide recovery was documented in three patients, further supporting the hypothesis of recovery of β cells and insulinopenia after the acute hyperglycemic emergency.…”

COVID-19 Vaccines and Hyperglycemia—Is There a Need for Postvaccination Surveillance?

“…Several instances of COVID-19 vaccination-induced hyperglycemia (ViHG) and related complications were reported [ 10 , 11 , 12 , 13 ]. Three diabetic individuals (one female and two males) presented with postvaccination hyperglycemia 1–6 days after receiving their first dose of the Covishield (AstraZeneca) vaccine [ 13 ].…”

“…Another study reported acute hyperglycemia 20–36 days after administration of the first dose of the Covishield (AstraZeneca) vaccine in three middle-aged obese dyslipidemic male patients (two of whom were prediabetic) [ 11 ]. ViHG was reported after the administration of the mRNA vaccines, Tozinameran/BNT162b2/Comirnaty (Pfizer/BioNTech) and mRNA-1273/Spikevax (Moderna) [ 10 , 12 ]. A summary of their available pre- versus postvaccination metabolic profiles and key data is presented in Table 1 .…”

“…A summary of their available pre- versus postvaccination metabolic profiles and key data is presented in Table 1 . Interestingly, all the reported cases maintained a proper glycemic control before COVID-19 vaccination/the reported episode of hospitalization and/or ICU care ( Table 1 ) [ 10 , 11 , 12 ]. In general, all patients presented with common osmotic symptoms of hyperglycemia (nocturia, polyuria, and polydipsia), and some reported significant weight loss, disorientation, and lightheadedness ( Table 1 ) [ 10 , 11 , 12 ].…”