Case report: Fulminant type 1 diabetes following paucisymptomatic SARS-CoV-2 infection during late pregnancy.

Background: Dysregulation of glucose metabolism has been linked to SARS-CoV-2 infection. In addition, the occurrence of new onset diabetes mellitus, including fulminant type 1 diabetes, has been reported after SARS-CoV-2 infection or vaccination. Methods and results: A young Chinese woman in her last trimester of pregnancy presented with an abrupt progression of hyperglycemia and ketoacidosis, but with a near-normal glycohemoglobin level following paucisymptomatic SARS-CoV-2 infection. The low C peptide levels, both fasting and postprandial, reflected profound insulin deficiency in the setting of negative islet autoantibody testing, consistent with a diagnosis of fulminant type 1 diabetes. Ketoacidosis and hyperglycemia quickly improved following the introduction of insulin therapy, but not the ß cell function. The patient received treatment with insulin pump therapy after being discharged, and the first follow-up revealed a well-controlled glucose profile. Conclusions: New-onset FT1D can occur after SARS-CoV-2 infection. Our report raises awareness of this rare but serious situation, promoting early recognition and management of FT1D during the COVID-19 pandemic.

COVID-19 associated ketosis and diabetic ketoacidosis: A rapid review.

SARS-CoV-2 infection could disrupt the endocrine system directly or indirectly, which could result in endocrine dysfunction and glycaemic dysregulation, triggering transient or persistent diabetes mellitus. The literature on the complex relationship between COVID-19 and endocrine dysfunctions is still evolving and remains incompletely understood. Thus, we conducted a review on all literature to date involving COVID-19 associated ketosis or diabetic ketoacidosis (DKA). In total, 27 publications were included and analysed quantitatively and qualitatively. Studies included patients with DKA with existing or new onset diabetes. While the number of case and cohort studies was limited, DKA in the setting of COVID-19 seemed to increase risk of death, particularly in patients with new onset diabetes. Future studies with more specific variables and larger sample sizes are needed to draw better conclusions.

New diagnoses of type 1 diabetes mellitus in children during the COVID-19 pandemic Regional multicenter study in Spain.

INTRODUCTION: The aim of this study is to determine whether during the year 2020, coinciding with the COVID-19 pandemic, there has been an increase in the incidence of diabetes mellitus in children compared to the previous 2 years. It is also to find out if lockdowns and the difficulty providing face-to-face care in the health system have led to children showing more severe symptoms at the time of diagnosis. MATERIAL AND METHODS: Retrospective observational multicenter study of the province of Tarragona where data is collected from new diagnoses of type 1 diabetes mellitus in patients under the age of 15 during the year 2020 and compared with years 2018 and 2019. RESULTS: The number of new diagnoses of type 1 diabetes during 2020 was 37 cases compared to 2019 and 2018 which was 23 and 29 respectively. The median age at onset was 9 years, 54% males. There was an increase in new diagnoses in the range of 10 to14-year-olds, with a decrease in the range of 0-4 year-olds. In 2020, the incidence in the group of patients with families from the Maghreb area rose from 52.2 cases per 100,000 population/year (c/105 p-y) in 2019 to 135.8 in 2020. Compared to the previous year, 2020 showed a significant decrease of ketoacidosis at the onset. None of the patients was diagnosed with COVID-19 during admission. CONCLUSION: During the year 2020 concurring with the COVID-19 pandemic, there was an increase in the number of new diagnoses of type 1 diabetes mellitus in pediatrics. Contrary to expectations, the presentation did not worsen by decreasing the proportions of ketoacidosis at onset. This data would suggest that, although attendance in the different health facilities dropped drastically during the year 2020 at the expense of virtual consultations, health systems and families were able to detect the symptoms of the disease early.

Diabetic ketoacidosis and Covid-19 management in a term pregnant patient; A case report (preprint)

Background: Covid-19 can have remarkable effects on pregnancy, and pregnant women with this infection are at higher risk for developing ketoacidosis. In this case report, we report a 35-year-old pregnant woman infected with Covid-19 with early manifestations of ketoacidosis during term pregnancy.

A Case Series of Ketoacidosis After Coronavirus Disease 2019 Vaccination in Patients With Type 1 Diabetes.

Introduction: We report a case series of severe ketoacidosis after COVID-19 vaccination in a type 1 diabetes patients treated with insulin and an SGLT-2 inhibitor. Case Report: We present two cases of type 1 diabetes mellitus. One patient was treated with insulin therapy and an SGLT-2 inhibitor, and the other patient was treated with insulin therapy alone. Both patients became ill after coronavirus disease-2019 vaccination, making it difficult to continue their diet or insulin injections. On admission, they developed severe diabetic ketoacidosis. This is the first report of ketoacidosis after coronavirus disease-2019 vaccination. Conclusion: The vaccine should be carefully administered to type 1 diabetes patients receiving intensive insulin therapy and a sodium-glucose transporter due to the high risk ketoacidosis. It is important to instruct patients to drink sufficient fluids and to continue insulin injections when they become sick.

Increase in the Number of Pediatric New-Onset Diabetes and Diabetic Ketoacidosis Cases During the COVID-19 Pandemic.

OBJECTIVE: Infection with SARS-CoV-2 induces a proinflammatory state that causes hyperglycemia and may precipitate diabetic ketoacidosis (DKA) in patients with known or new-onset diabetes. We examined the trends in new-onset diabetes and DKA prior to and following the onset of the COVID-19 pandemic. METHODS: This single-center retrospective observational study included pediatric patients (aged 0 to <18 years) hospitalized with new-onset type 1 diabetes or type 2 diabetes (T2D) before (March 1, 2018, to February 29, 2020) and after (March 1, 2020 to December 31, 2020) the pandemic onset. Demographic, anthropometrics, laboratory and clinical data, and outcomes were obtained. RESULTS: Among 615 children admitted with new-onset diabetes during the entire study period, 401 were admitted before the pandemic onset, and 214 were admitted after the pandemic onset. Children admitted with new-onset diabetes in the postpandemic period were significantly more likely to present with DKA (odds ratio, 1.76; 95% confidence interval, 1.24-2.52) than in the prepandemic phase. Children with DKA after the pandemic onset had higher lengths of hospitalization and were significantly more likely to experience severe DKA (odds ratio, 2.17; 95% confidence interval, 1.34-3.52). A higher proportion of children with DKA admitted to the pediatric intensive care unit required oxygen support after the pandemic onset than before the pandemic onset (8.85% vs 1.92%). Most cases of T2D with DKA occurred following the onset of the pandemic (62.5%). CONCLUSION: A significant increase in T2D cases occurred following the onset of the COVID-19 pandemic with a greater risk of DKA and severe ketoacidosis. Racial disparity was evident with a higher proportion of Black and American Indian children presenting with ketoacidosis following the pandemic onset.

Diabetes-related excess mortality in Mexico: a comparative analysis of national death registries between 2017-2019 and 2020 (preprint)

BACKGROUND: Excess all-cause mortality rates in Mexico in 2020 during the COVID-19 pandemic were among the highest globally. Recent reports suggest that diabetes-related deaths were also higher, but the contribution of diabetes as a cause of excess mortality in Mexico during 2020 compared to prior years has not yet been characterized. METHODS: We conducted a retrospective, state-level study using national death registries from Mexican adults [≥]20 years for the 2017-2020 period. Diabetes-related deaths were classified using ICD-10 codes that listed diabetes as the primary cause of death, excluding certificates which listed COVID-19 as a cause of death. Excess mortality was estimated as the increase in diabetes-related mortality in 2020 compared to average rates in 2017-2019. Analyses were stratified by diabetes type, diabetes-related complication, and in-hospital vs. out-of-hospital death. We evaluated the geographic distribution of diabetes-related excess mortality and its socio-demographic and epidemiologic correlates using spatial analyses and negative binomial regression models. RESULTS: We identified 148,437 diabetes-related deaths in 2020 (177/100,000 inhabitants), 41.6% higher than the average for 2017-2019, with the excess occurring after the onset of the COVID-19 pandemic. In-hospital diabetes-related deaths decreased by 17.8% in 2020 compared to 2017-2019, whereas out-of-hospital deaths increased by 89.4%. Most deaths were attributable to type 2 diabetes and type 1 diabetes (129.7 and 4.0/100,000 population). Diabetes-related emergencies as contributing causes of death also increased in 2020 compared to 2017-2019 for hyperglycemic hyperosmolar state (128%), and ketoacidosis (116%). Diabetes-related excess mortality clustered in southern Mexico and was highest in states with higher social lag, higher rates of COVID-19 hospitalization, and higher prevalence of HbA1c [≥]7.5%. INTERPRETATION: Diabetes-related mortality increased among Mexican adults by 41.6% in 2020 after the onset of the pandemic compared to 2017-2019, largely attributable to type 2 diabetes. Excess diabetes-related deaths occurred disproportionately out-of-hospital, clustered in southern Mexico, and were associated with higher state-level marginalization, rates of COVID-19 hospitalizations, and higher prevalence of suboptimal glycemic control. Urgent policies to mitigate mortality due to diabetes in Mexico are needed, particularly given the ongoing challenges in caring for people with diabetes posed by the COVID-19 pandemic.

Evaluation of Renal Function in COVID-19 Patients by Using Urinalysis Following the Administration of Vancomycin.

BACKGROUND: The aim of this study was to evaluate renal function by urinalysis in COVID-19 patients following the administration of vancomycin. METHODS: A retrospective observational study was performed between October 2020 and January 2021, during which time patients were hospitalized in the Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia. The patients were free of kidney disease. Urinalysis was performed by an automated laboratory system, and the collected results were based upon age, gender, diabetic status, whether the patients had received vancomycin, the mortality rate, and the urinalysis panel including coinfection by bacteria and yeast. RESULTS: A total of 227 patients were included in this study, 147 (64.75%) of whom were male and 80 (35.25%) of whom were female; 54.63% were diabetic, 11.89% were prediabetic, and 33.48% were non-diabetic patients. Proteinuria, hematuria, glycosuria, coinfection, and ketonuria were detected among all participants within the study group, specifically among diabetic patients. The mortality rate was 16.2% among the study group; 6.6% had re-ceived vancomycin, and 9.6% had not received vancomycin. No significant correlation was found between nephrotoxicity and abnormalities in the urine and the mortality rate among members of our study group. CONCLUSIONS: Proteinuria, hematuria, glycosuria, ketonuria, and coinfection were common among members of our study group, especially in the diabetic group. Urinalysis abnormalities were less frequent in the vancomycin group than in the others, except the prediabetic group. No correlation between mortality and vancomycin was identified.

Critical COVID-19 in a pregnant patient who presented in starvation ketoacidosis with a background history of acrorenal syndrome.

A primiparous woman in her late 30s at 28+1 weeks' gestation presented with a 3-day history of abdominal pain, loss of appetite, nausea and vomiting and was diagnosed with starvation ketoacidosis. A routine admission swab returned positive for COVID-19. She had been diagnosed with acrorenal syndrome from birth. Three days post admission, she deteriorated rapidly into respiratory failure requiring intubation and ventilation. She was treated with dexamethasone, prophylactic enoxaparin, a course of piperacillin/tazobactam followed by meropenem and fluconazole and 8 cycles of proning. An emergency caesarean section was performed on day 12 of hospital admission at 29+5 weeks' gestation to improve maternal oxygenation and ventilation. The baby had deformities consistent with acrorenal syndrome but no evidence of COVID-19. She spent 23 days in the intensive care unit. Our case describes an unusual presentation of COVID-19, the challenges in managing critically ill pregnant patients along with a rare background history of acrorenal syndrome.

Emergence of Autoimmune Type 1 Diabetes and Acute Adrenal Crisis Following COVID-19 (preprint)

Objective: Several case reports have indicated a possible link between Coronavirus Disease 2019 (COVID-19) and new-onset autoimmune disorders while co-precipitation of autoimmune type 1 diabetes and Addison’s disease has never been reported to date. Case Description: A 60-year-old male presented with extreme fatigue and weight loss three weeks after testing positive for COVID-19. The course of COVID-19 was mild, without pulmonary involvement. The patient showed symptoms and laboratory signs of new-onset diabetes without ketoacidosis and acute primary adrenal insufficiency, latter of which was confirmed with an ACTH stimulation test. GAD-65 antibody and antibodies to the adrenal cortex were positive in high titers, and the patient also had primary hypothyroidism associated with autoimmune thyroiditis. Previous medical records of the patient revealed no hyperglycemia or electrolyte abnormalities prior to current admission, but an earlier test result compatible with primary hypothyroidism. The patient was diagnosed with autoimmune polyglandular syndrome type II (APS II). Clinical and laboratory findings improved after starting appropriate hormone replacement therapies along with insulin. Conclusions: : Evidence mostly obtained from case reports suggests that COVID-19 may induce a variety of autoimmune disorders in susceptible subjects. In our case, COVID-19 might have simply precipitated T1D and adrenal crisis in whom autoimmune thyroiditis may have been the first manifestation of an undiagnosed APS II. Or, COVID-19 may have triggered autoimmunity in the patient who was possibly predisposed to autoimmune disorders, and led to the development of APS II. Anyhow, more research is required to evaluate the possible link between COVID-19 and autoimmune disorders.

Mucormycosis infection in severe COVID-19 patient with multiple underlying health conditions (preprint)

Coronavirus disease 2019 (COVID-19) is a fearsome infectious disease which cause some excessive complications along with it. the authors present a case of acute invasive rhino-orbital mucormycosis in a 62-year-old man with severe COVID-19 pneumonia, who had a history of uncontrolled diabetes mellitus along with ketoacidosis and nephropathy.

Euglycaemic ketoacidosis in pregnant women with COVID-19: two case reports.

BACKGROUND: Euglycaemic ketoacidosis (EKA) is an infrequent but serious condition which usually follows a period of starvation, severe vomiting or illness in individuals with or without diabetes. Ketoacidosis is associated with materno-fetal morbidity and mortality necessitating prompt diagnosis and management. Physiological increases in insulin resistance render pregnancy a diabetogenic state with increased susceptibility to ketosis. COVID-19 is associated with worse clinical outcomes in patients with diabetes and is an independent risk factor for ketoacidosis in normoglycaemic individuals. CASE PRESENTATIONS: We describe two cases of SARS-CoV-2 positive pregnant women presenting with normoglycaemic metabolic ketoacidosis. Both cases were associated with maternal and fetal compromise, requiring aggressive fluid and insulin resuscitation and early delivery. CONCLUSION: We discuss possible physiology and propose a management strategy for euglycaemic ketoacidosis in pregnancy.

Severe metabolic ketoacidosis as a primary manifestation of SARS-CoV-2 infection in non-diabetic pregnancy.

We present a case of a metabolic acidosis in a term-pregnant woman with SARS-CoV-2 infection.Our patient presented with dyspnoea, tachypnoea, thoracic pain and a 2-day history of vomiting, initially attributed to COVID-19 pneumonia. Differential diagnosis was expanded when arterial blood gas showed a high anion gap metabolic non-lactate acidosis without hypoxaemia. Most likely, the hypermetabolic state of pregnancy, in combination with maternal starvation and increased metabolic demand due to infection, had resulted in metabolic ketoacidosis. Despite supportive treatment and rapid induction of labour, maternal deterioration and fetal distress during labour necessitated an emergency caesarean section. The patient delivered a healthy neonate. Postpartum, after initial improvement in metabolic acidosis, viral and bacterial pneumonia with subsequent significant respiratory compromise were successfully managed with oxygen supplementation and corticosteroids. This case illustrates how the metabolic demands of pregnancy can result in an uncommon presentation of COVID-19.

Can ketone bodies inactivate coronavirus spike protein? The potential of biocidal agents against SARS-CoV-2.

Biocidal agents such as formaldehyde and glutaraldehyde are able to inactivate several coronaviruses including SARS-CoV-2. In this article, an insight into one mechanism for the inactivation of these viruses by those two agents is presented, based on analysis of previous observations during electron microscopic examination of several members of the orthocoronavirinae subfamily, including the new virus SARS-CoV-2. This inactivation is proposed to occur through Schiff base reaction-induced conformational changes in the spike glycoprotein leading to its disruption or breakage, which can prevent binding of the virus to cellular receptors. Also, a new prophylactic and therapeutic measure against SARS-CoV-2 using acetoacetate is proposed, suggesting that it could similarly break the viral spike through Schiff base reaction with lysines of the spike protein. This measure needs to be confirmed experimentally before consideration. In addition, a new line of research is proposed to help find a broad-spectrum antivirus against several members of this subfamily.

Secondary infection with rhino-orbital cerebral mucormycosis associated with COVID-19.

We report two fatal cases of rhino-orbital-cerebral mucormycosis associated with COVID-19 infection. Both patients had pre-existing diabetes mellitus type 2, were treated with corticosteroids, and developed ketoacidosis. Both patients rapidly declined owing to rapid extension of the infection into the intracranial cavity. We postulate that additional risk factors for opportunistic fungal infection exist in COVID-19 patients including mechanical ventilation and Sars-CoV-2 induced immunosuppression. The ophthalmologist's role is particularly important in the early diagnosis of mucormycosis associated with COVID-19.

Euglycaemic ketoacidosis in a pregnant woman with COVID-19 pneumonia. A case report / Cetoacidosis normoglicémica en paciente embarazada con neumonía por COVID-19. Reporte de un caso clínico

RESUMEN Introducción: La cetoacidosis en el embarazo es una emergencia médica que requiere tratamiento en Unidad de Cuidados Intensivos debido a su asociación con morbimortalidad maternofetal. Las gestantes pueden presentar una forma atípica del cuadro llamada cetoacidosis normoglicémica, siendo muy infrecuente en pacientes sin antecedente de diabetes. Caso Clínico: Se presenta una gestante cursando tercer trimestre de embarazo, sin antecedente de diabetes, ingresada en Unidad de Paciente Crítico debido a neumonía por COVID-19 y acidosis metabólica con anión gap aumentado. Se realizó diagnóstico de cetoacidosis normoglicémica posterior al ingreso, iniciándose tratamiento intensivo de trastorno ácido-base con buena evolución. Conclusión: La infección por SARS-CoV-2 puede causar cetoacidosis normoglicémicas en embarazadas no diabéticas; se requiere una alta sospecha clínica para realizar el diagnóstico y tratamiento oportuno.

ABSTRACT Introduction: Ketoacidosis in pregnancy is a medical emergency that requires treatment in an intensive care unit due to its association with maternal-fetal morbimortality. Pregnant women may present an atypical form of the condition called normoglycemic ketoacidosis, being very rare in patients with no history of diabetes. Clinical Case: We present a pregnant woman in the third trimester of pregnancy, without history of diabetes, admitted to a critical patient unit due to COVID-19 pneumonia and metabolic acidosis with an increased anion gap. A diagnosis of normoglycemic ketoacidosis was made after admission, and intensive treatment of acid-base disorder was initiated, with good evolution. Conclusion: SARS-CoV-2 infection can cause normoglycemic ketoacidosis in non-diabetic pregnant women; is required a high clinical suspicion to make the diagnosis and appropriate treatment.