Diabetic ketoacidosis in an adolescent with type 2 diabetes and COVID-19 pneumonia

ABSTRACT

In December 2019, the world witnessed an outbreak of COVID-19 caused by the severe acute respiratorysyndrome coronavirus 2 (SARS-CoV-2). Although children and adolescents comprise approximately 22% of theUS population, only 1.7% of total Covid-19 cases have occurred in patients <18 years of age with 3-deaths asreported recently by the CDC. Case We report on a case of a 17-year old Hispanic female who was previouslydiagnosed with T2DM and presented with diabetic ketoacidosis (DKA) and Covid-19 pneumonia. The patient'smedical history was significant for T2DM diagnosed a year earlier, she had tested negative for insulinautoantibodies and glutamic acid decarboxylase autoantibodies. The patient experienced cough and fever 1-day prior to presentation that worsened progressively with multiple vomiting episodes and altered sensoriuma few hours prior to presentation. On arrival at the emergency department the patient was lethargic, illappearing with dry mucous membranes. Vital signs temperature 36.3 °C, heart rate 128/min, bloodpressure 136/85 mmHg, and Kussmaul respirations with a rate of 28/min. Chest auscultation revealed clear breath sounds with no adventitious sounds and her oxygen saturation was 100% by pulse oximetry. Initialvenous blood gas analysis showed profound metabolic acidosis (pH, 6.84;PCO2, 22.0 mmHg;PO2, 48 mmHg;HCO3, 6.5 mmol/L). She had significant hyperglycemia (526 mg/dl) and her urinalysis showed ketonuriaindicative of DKA with poorly controlled T2DM (HbA1c 15.3%). Chest X-ray showed a patchy infiltrate on theright upper lobe that was suspicious for Covid-19 pneumonia (Figure 1.). Patient was administeredintravenous fluids and a continuous infusion of insulin as per DKA protocol and was transferred to theintensive care unit with precautions for Covid-19. Patient's hospitalization was significant for a positive resulton the Covid-19 PCR test. Her respiratory status remained stable and she required oxygen supplementationby nasal cannula. Although her metabolic acidosis improved within 48-72 hours, she had persistenthypokalemia and hypophosphatemia (Figure 2) that required correction with potassium phosphate andpotassium chloride. She also had a relatively slow improvement in her mental status and had diarrhea duringhospitalization. The patient was discharged on day-6 of hospitalization with no complications. Discussion: Afew recent studies have shown that infection with Covid-19 in adults with diabetes is associated with poorclinical outcomes and higher mortality rates. In a smaller study, Covid-19 infection was shown to induceketoacidosis in adult T2DM patients. However, comparable studies in children with T2DM and Covid-19 areunavailable. Although DKA is uncommon in T2DM, it can occur secondary to stressors such as an infectionwith Covid-19 that increases secretion of catabolic hormones like glucagon in a setting of insulin deficiency.Ours is the first study to report Covid-19 infection induced DKA in an adolescent with poorly controlled T2DM. (Figure Presented).