ABSTRACT
Introduction: The aim of this study was to improve treatment of corticosteroid induced hyperglycaemia in patients critically unwell with COVID-19. Management with high dose steroids reduces mortality and has become standard practice. However, high dose glucocorticoid therapy impairs glucose metabolism in patients already at risk of insulin resistance and impaired insulin production, resulting in increased incidence of hyperglycaemia [1]. Methods: A retrospective audit was undertaken, collecting data on steroid use, glycaemic control, and insulin treatment in 100 patients admitted to the Royal Cornwall Hospital Intensive Care Unit with COVID-19. A standard operating procedure (SOP) for the treatment of steroid induced hyperglycaemia was created, based on guidelines from the National Inpatient Diabetes COVID-19 Response Group [1]. Results: Of 100 patients, 91 received high dose steroids. The majority (64.8%) experienced glycaemic control issues, defined as one episode of blood sugar > 12 mmol/l. Of the patients treated with 6 mg dexamethasone 52% experienced hyperglycaemia, compared to 71% of those treated with higher steroid doses. There was no significant difference in the highest blood sugar level of either cohort (t54 = - 0.450, p = 0.654). The average time between first episode of hyperglycaemia and commensal of insulin was 76 h. There was a lack of consensus in management of steroid-induced hyperglycaemia-no treatment was administered in 37% of patients. In those who were treated, 19 different combinations of insulin were given. Sliding scale insulin was administered in most patients who experienced no further hyperglycaemia. Conclusions: These results highlight a necessity for consensus management of steroid induced hyperglycaemia. In line with these findings, the devised SOP recommends initial therapy with rapid acting insulin and administration of a sliding scale if hyperglycaemia persists.
ABSTRACT
Introduction: Covid-19, a novel Coronavirus SARS-COV-2, has caused major morbidity and mortality worldwide most especially in the high-risk population. SARS-COV-2 has caused more unfavorable outcomes and increased insulin resistance in patients with diabetes mellitus. It has been observed that many of these patients require very high doses of insulin to manage hyperglycemia. This will discuss a case of a young male with newly diagnosed type 2 diabetes complicated with Covid-19 infection. Case Description: 38-year-old Hispanic male with no past medical history presented to the emergency department with shortness of breath, cough, and chest congestion. His only medication was azithromycin. He had no family history of diabetes mellitus. There was no acanthosis nigricans on examination and the patient's BMI was 26.7 kg/m 2 . The patient was admitted for severe acute respiratory syndrome and diabetic ketoacidosis. His hba1c level was 13.7%, c-peptide was inappropriately low with a value of 0.31 ng/mL and glucose of 153 mg/dL and GAD-65 and islet cell antibodies were negative. Endocrinology was consulted for diabetic management. The patient was started on basal insulin 5 units at bedtime;however, the dose was increased to 7 to 9 to 12 and then 20 units at bedtime due to uncontrolled sugar levels. The patient was started on short-acting insulin before meals because his glucose ranged from 156 mg/dL to 381 mg/dL. The patient clinically improved and was discharged on hospital day 12. He got discharged on insulin detemir 20 units at bedtime and insulin lispro 8 units before meals. On a visit to the clinic, the patient was weaned off of insulin due to better glycemic control. His hba1c level significantly dropped to 7.2% and his c-peptide level improved to 3.21 ng/mL. He is now been controlled only on metformin 1000mg twice a day. Discussion: There is no definite explanation for why SARS-COV- 2 infection causes new-onset diabetes and worsening insulin resistance. However, there have been some theories attributed to the effects of the SARS-COV-2 coronavirus on angiotensin-converting enzyme 2 (ACE2). ACE2 is present in metabolic organs and tissues including pancreatic beta cells. As a result, an infection with the SARS-COV-2 virus could affect the pathophysiology of glucose metabolism causing increase insulin resistance. Another theory explains that coronavirus could cause ketosis-prone diabetes causing diabetic ketoacidosis in patients with no known history of hyperglycemia. Therefore, Covid-19 has some association with diabetes mellitus management outcomes.
ABSTRACT
The novel coronavirus infection involves both the Central and Peripheral Nervous systems. Some of the presentations include acute cerebrovascular disease, impaired consciousness, transverse myelitis, encephalopathy, encephalitis, and epilepsy. Our patient was a 78-year-old man with dementia and diabetic nephropathy who was admitted two times for possibly COVID-19 infection. At the first hospitalization, the patient is treated with hydroxychloroquine and Kaletra based on clinical symptoms and initial laboratory findings due to suspicion of COVID-19. After the negative RT-PCR test of the nasopharyngeal sample for COVID-19 and evidence of aspiration pneumonia in CT scan, the patient was discharged with oral antibiotics. Five weeks later, he was rehospitalized with loss of consciousness, fever, and hypoxemia in the physical exam;he had neck stiffness in all directions, So the central nervous system (CNS) infection was suspected, the cerebrospinal fluid (CSF) sample was in favor of aseptic meningitis and second RT-PCR test of nasopharyngeal sample for COVID-19 was positive, but Brain MRI just showed small vessel disease without evidence of encephalitis. In the second hospitalization, he had acute renal failure, which was treated with supportive care, and also suffered from pulmonary embolism with cavitary lesions in his lungs. Meningitis with pulmonary embolism and acute renal failure have not yet been reported. Our patient is the first one, so we decided to share it. This case showed a different presentation of COVID-19 without typical lung involvement. So, we must pay attention to any signs and symptoms in a patient suspected of having a COVID-19.