P0458 - Diabetic Ketoacidosis in an Adolescent with Type 2 Diabetes and Covid-19 Pneumonia

In December 2019, the world witnessed an outbreak of COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although children and adolescents comprise approximately 22% of the US population, only 1.7% of total Covid-19 cases have occurred in patients <18 years of age with 3-deaths as reported recently by the CDC.

Case: We report on a case of a 17-year old Hispanic female who was previously diagnosed with T2DM and presented with diabetic ketoacidosis (DKA) and Covid-19 pneumonia. The patient’s medical history was significant for T2DM diagnosed a year earlier, she had tested negative for insulin autoantibodies 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 sensorium a few hours prior to presentation. On arrival at the emergency department the patient was lethargic, ill appearing with dry mucous membranes. Vital signs: temperature: 36.3 °C, heart rate: 128/min, blood pressure: 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. Initial venous 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 ketonuria indicative of DKA with poorly controlled T2DM (HbA1c: 15.3%). Chest X-ray showed a patchy infiltrate on the right upper lobe that was suspicious for Covid-19 pneumonia (Figure 1.). Patient was administered intravenous fluids and a continuous infusion of insulin as per DKA protocol and was transferred to the intensive care unit with precautions for Covid-19. Patient’s hospitalization was significant for a positive result on the Covid-19 PCR test. Her respiratory status remained stable and she required oxygen supplementation by nasal cannula. Although her metabolic acidosis improved within 48-72 hours, she had persistent hypokalemia and hypophosphatemia (Figure 2) that required correction with potassium phosphate and potassium chloride. She also had a relatively slow improvement in her mental status and had diarrhea during hospitalization. The patient was discharged on day-6 of hospitalization with no complications.

Discussion: A few recent studies have shown that infection with Covid-19 in adults with diabetes is associated with poor clinical outcomes and higher mortality rates. In a smaller study, Covid-19 infection was shown to induce ketoacidosis in adult T2DM patients. However, comparable studies in children with T2DM and Covid-19 are unavailable. Although DKA is uncommon in T2DM, it can occur secondary to stressors such as an infection with 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.