Onset of Ketosis-Prone Diabetes in the Setting of COVID-19 Infection

Abstract

Diabetic ketoacidosis is typically associated with type I diabetes mellitus, but it can be associated with type II diabetes mellitus under the conditions of extreme stress or as a presenting manifestation of ketosis-prone type II diabetes mellitus. A 38-year-old prediabetic male presented to the emergency room with hyperglycemia six weeks after recovery from coronavirus disease 2019 (COVID-19) pneumonia. Laboratory results showed severe hyperglycemia, metabolic acidosis, positive ketones in urine and blood, and elevated fasting C- peptide level. COVID-19 polymerase chain reaction (PCR) was negative, and immunoglobulin G (IgG) antibodies were positive. The workup was completely unremarkable for acute infection. Hemoglobin A1C increased from 6.1% to 10.8% within six weeks. The mechanism by which COVID-19 infection may trigger the onset of full-blown diabetes mellitus remains unknown. Viral infection may cause the direct destruction of pancreatic beta cells or trigger the changes in the body that induce the state of insulin resistance. Antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may cross-react or interfere with the functioning of endogenous insulin. The association between type II diabetes and COVID-19 infections needs additional investigations to ascertain the exact mechanism by which COVID-19 infection triggers the onset of full-blown diabetes mellitus.

Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection

“…New onset insulin-requiring diabetes in patients with COVID-19 has been reported in multiple studies and appears to persist after recovery from acute infection ( 118 , 120 , 121 , 122 , 123 ). Patients may present with severe hyperglycemia, including hyperosmolarity or ketoacidosis, or with milder hyperglycemia ( 124 , 125 , 126 , 127 ). Patients with more severe manifestations of acute COVID-19 appear to be at higher risk, with noted correlation between hypoxia and hyperglycemia among hospitalized patients without preexisting diabetes and prior to administration of glucocorticoid therapy ( 128 ).…”

Does COVID-19 Cause New-Onset Diabetes or Unmask Pre-Existing Diabetes?

“…Yet, 6 weeks after recovery from COVID-19 pneumonia, he presented with DKA. His biochemical profile was consistent with type 2 diabetes as evidenced by normal C-peptide levels, and negative antibodies against islet cell, zinc transporter 8, insulin, and weakly positive anti-GAD antibodies [12]. Interestingly, on this second admission, his polymerase chain reaction (PCR) was negative for COVID-19 and his HbA1c value was 10.8% implying that blood glucose levels started to rise rapidly after the initial COVID-19 pneumonia 6 weeks earlier [12].…”

“…To the best of the authors' knowledge, only one case report has provided some evidence that COVID-19 may cause new-onset type 2 diabetes [12]. Thus, Siddiki et al [12] described a 58 years-old man from Jamaica who initially presented with COVID-19 pneumonia. His HbA1c level during this initial presentation was 6.1%, i.e., in the prediabetes range [12].…”

“…Thus, Siddiki et al [12] described a 58 years-old man from Jamaica who initially presented with COVID-19 pneumonia. His HbA1c level during this initial presentation was 6.1%, i.e., in the prediabetes range [12]. Yet, 6 weeks after recovery from COVID-19 pneumonia, he presented with DKA.…”

Marked hyperglycemia and ketosis in a non-obese patient with new onset diabetes and very mild COVID-19 symptoms: A case report

“…He quickly responded to oral anti-hyperglycaemic agents without addition of insulin. In difference all, except a few, reported patients with new-onset diabetes and ketosis/ketoacidosis had severe COVID-19 infection with presence of markedly elevated inflammatory markers [ [7] , [8] , [9] ] On review of literature only three cases, similar to our case, have been reported previously [ 10 ]. All the three cases had mild symptoms of COVID-19.…”