Diabetic Ketoacidosis and COVID-19: Two Case Reports
Mehdi Kafi1, Maryam Karimi Fard 2*, Sima Amiorroaya Yamini 3
1. Student Research Committee, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
2. Assistant Prof., Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
3. Associate Prof., Dept. of Engineering and Mathematics, Sheffield Hallam University, Sheffield S1 1WB, UK.
* Corresponding author: Maryam Karimi Fard; E-mail: m.karimifard@rums.ac.ir
Abstract
Background: COVID-19 is a viral infection that causes pneumonia with dyspnea, cough, and fever. Its outcomes are more severe in patients with diabetes, hypertension, and other disorders than in healthy people. New-onset diabetes and diabetic ketoacidosis (DKA) have been reported as the complications of COVID-19 in several studies. It seems that the prevalence of DKA due to Covid-19 is increasing. Therefore, two cases of individuals with DKA due to COVID-19 are presented in this study to inform other researchers about the details of this phenomenon.
Material and Methods: Demographic characteristics, medical histories, physical examinations, laboratory investigations, real-time RT-PCR tests, computed tomography (CT) imaging studies, given treatments, clinical courses, and management outcomes were documented prospectively.
Results: In the present experience, the manifestation of COVID-19 disease in the second case with a history of diabetes was more severe than in the first case. In the second case, with underlying diabetes and COVID-19, the DKA manifestation was associated with consciousness loss, severe restlessness, and respiratory distress; however, in the first case, with COVID-19 without diabetes, the DKA manifestation was associated with anorexia, weight loss, and lack of respiratory distress, which were milder symptoms than the second case.
Conclusion: Due to the high prevalence of diabetes mellitus and COVID-19 in Iran, it is recommended to raise awareness of DKA symptoms among health professionals.
Keywords: Diabetes Complications, Diabetic Ketoacidosis, Covid-19.
Introduction
COVID-19 was first diagnosed with pneumonia in December 2019 in Wuhan, China [1]. Patients can be asymptomatic or exhibit a mild upper respiratory failure to severe pneumonia with respiratory failure and even death [2,3]. Symptoms, including fever, cough, dyspnea, muscle aches, nausea, vomiting, headache, sore throat, chest pain, and diarrhea, can also vary from patient to patient [4]. On the other hand, the disease mortality rate is directly related to age, underlying diseases, such as diabetes, cardiovascular disorders, and cancer [4].
DKA, which can be fatal, is a disorder characterized by metabolic acidosis (pH <7.35 or serum bicarbonate ≤15 mmol/L), ketonemia or ketonuria, and hyperglycemia (blood glucose ≥ 250 mg/dL) [5]. It occurs in patients with diabetes, especially type 1, due to factors such as missing the insulin doses and significant physical or emotional stress, including infections [6]; it can also be present with sudden metabolic decompensation [7]. During the pandemic, several new-onset diabetes with DKA have been reported in COVID-19 patients [8, 9]. Here, the clinical and paraclinical features of two Covid-19 patients, one with a history of type 2 diabetes (T2D) and one with no history of diabetes eventually hospitalized due to DKA, are investigated. It seems that the prevalence of DKA due to Covid-19 is increasing; thus, in the present research, two cases of individuals with DKA due to COVID-19 are presented to raise awareness of DKA symptoms among health professionals at the time of the Covid-19 pandemic.
Materials and Methods
Demographic characteristics, detailed drug and medical histories, physical examinations, laboratory investigations, including Hematology, Biochemistry, Urine analysis, and Arterial Blood Gases (ABG), as well as real-time RT-PCR tests, computed tomography (CT) imaging studies for Covid-19, given treatments, clinical courses, and management outcomes, were documented prospectively. Informed consent was obtained from both patients for the study. Diabetic ketoacidosis was defined as plasma glucose >250 mg/dL, a positive test for urine ketones, and arterial pH < 7.35.
Written informed consent was obtained from the patients. Since this was a case report but not a clinical study, ethics approval was unnecessary.
Results
Case 1: The first patient was a 48-year-old male, an Iranian farmer, who presented to the emergency department of Aliebne Abitaleb General Hospital in Rafsanjan, Iran, with fever and dyspnea. Due to suspicion of contact with the Covid-19 patient, a chest CT scan and RT-PCR test were conducted. The ground-glass opacity was observed in the lower and upper lobes of the right lung and the lower lobe of the left lung, and atelectasis was observed in the lower lobe of the left lung and lingula in the chest CT scan, confirming lung involvement (Fig.1). The patient's RT-PCR was also tested positive, confirming the diagnosis of COVID-19. Therefore, the patient underwent outpatient treatment and self-isolation at home. During the treatment course, he was prescribed intravenous dexamethasone, 8mg daily for 10 days, subcutaneous interferon-beta injections (Recigen), 44µg for 5 days every other day, with liver function monitoring tests, and a dose of Neurobion ampoule. Twelve days later, the patient was presented to the emergency department with anorexia, severe weight loss of 17kg (88kg to 71kg), polyuria and polydipsia in the last two weeks, and severe weakness on the day of admission. He exhibited no respiratory symptoms and had no history of diabetes or any other diseases. He had no history of drinking alcohol and/or using drugs, and of close relatives, only his uncle had T2D. The patient had no drug allergy or addiction. At admission, he had a body temperature of 36 degrees, pulse rate of 141 beats/minute, respiratory rate of 18 breaths/minute, blood pressure of 100/70 mmHg, body mass index (BMI) of 21.91 kg/m2 (height 180 cm), and oxygen saturation of 93% by pulse oximetry on ambient air. On examination, the patient was alert and showed severe dehydration signs, including weakness, rapid pulse, dry tongue, and skin. Chest X-ray was normal. Laboratory evaluation was notable for DKA (Table 1), with a random blood glucose of 800 mg/dl and HbA1C of 10.3%. Metabolic acidosis (bicarbonate=8.4) was also detected by arterial blood gas (ABG). His urine dipstick test was positive for ketones. Due to a history of COVID-19, the patient underwent another chest CT scan, which came back clear. Therefore, the patient was admitted to the hospital with the diagnosis of new-onset diabetes with DKA. He was started on infusion regular insulin, aggressive intravenous hydration, electrolyte replacement, and supportive measures. The patient's DKA was treated after 16 hours. Finally, the patient was discharged after treatment with a subcutaneous insulin regimen.