COVID-19 and Emergencies in Patients With Diabetes

In This Article

Abstract and Introduction

Abstract

Background: Maldives reported its first Coronavirus disease 2019 (COVID-19) case on March 7th, 2020. Since then more than 9400 positive cases and 33 deaths have been reported. Recently studies have shown that COVID-19 patients with diabetes had a poor prognosis and a higher mortality rate when compared to the non-diabetic patients. Poorly controlled diabetic patients had a higher incidence of complications like diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) which might have been precipitated by COVID-19. DKA and HHS are potentially lethal but preventable conditions. During this pandemic, although cases of uncontrolled diabetes are frequently reported, there is scarcity in reporting of cases with diabetic emergencies.

Case Presentation: Case 1 was a 53-year old Asian male, admitted on Day 10th of illness with DKA with acute kidney injury, and Moderate COVID-19. Case 2 was a 72-year old Asian male, admitted with mild COVID-19 who developed HHS with acute kidney injury on day 9 of illness. Both patients were managed conservatively in intensive care unit, with intravenous fluids and insulin.

Conclusion: Clinicians should focus on close monitoring of diabetic patients with COVID-19, to prevent diabetic emergencies like DKA and HHS. It is important to aggressively manage these conditions for a favorable outcome.

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak began in China in December 2019.^[1] The World Health Organization (WHO) declared COVID-19 as a pandemic on March 11th, 2020^[2] and since then there have been over thirty million confirmed cases and over nine hundred thousand deaths worldwide.^[3] Maldives confirmed its first case of COVID-19 on March 7th, 2020 and till date, more than nine thousand four hundred cases and thirty-three deaths have been reported.^[4]

Studies have shown that elderly age and people of any age with certain medical conditions like diabetes mellitus, cardiovascular disease, cancer, obesity, chronic obstructive pulmonary disease, and chronic kidney disease are at increased risk of severe disease and mortality from COVID-19.^[5]

The prevalence of diabetes in 1590 Chinese patients with COVID-19 was 8.2%. However, the prevalence of diabetes increased to 34.6% in patients with severe COVID-19.^[6] In a recent study done in New York City (USA) in patients with COVID-19, the prevalence of diabetes and obesity was higher in individuals admitted to hospital than those not admitted to hospital (34·7% vs 9·7% for diabetes and 39·5% vs 30·8% for obesity, respectively).^[7] In Italy, it was reported that 35.5% of patients who died from COVID-19 had diabetes, a prevalence greater than 3 times that of the general population.^[8]

A survey done in England (UK) showed that out of the 23 804 patients with COVID-19 who died in hospital, 32% had type 2 diabetes and 1.5% had type 1 diabetes, with 2.03 and 3.5 times the odds of dying compared with patients without type 2 diabetes and type 1 diabetes respectively.^[9] The French CORONADO study revealed 3% had type 1 diabetes, 88·5% had type 2 diabetes, 5·4% had other type diabetes, and 3·1% were diagnosed at admission.^[10] All these studies have shown that diabetic patients with COVID-19 had a worse prognosis and a higher mortality rate.

Diabetic emergencies like DKA and HHS are life-threatening but preventable. These complications can be precipitated by any infectious disease including COVID-19. Here we describe two cases of critical COVID-19 complicated by DKA and HHS managed in the Maldives.

Table 1. Laboratory investigations in case 1
	25/07/2020	26/07/2020	27/07/2020	28/07/2020	29/07/2020	30/07/2020	02/08/2020
Hemoglobin, g/dl [range: 14–18]	14.7	12.8	13.4	12.0	12.3	12.3	12.7
Hematocrit, % [range: 40–54]	55.7	41.9	40.2	37	37.6	37.7	39
Leukocytes, 10³/ml [range: 5.0–10.0]	7.20	9.16	8.12	7.18	5.78	3.92	6.56
Neutrophils % [range: 45–74]	73.9	81.5	77.9	74.5	80.9	53.6	50.7
Lymphocytes, % [range: 16–45]	19.6	15.9	19.4	23.6	14.6	35.3	40.3
Platelets, 10³/ml [range: 150–450]	261	148	106	68.6	63.9	94.5	236
Urea, mg/dl [range: 19–44.1]	136.9	74.9	51.36	34.24	32.10	38.52
Creatinine, mg/dl [range: 0.8–1.25]	2.9	1.4	1.19	0.90	0.78	0.83
Na, mEq/L [range: 135–145]	149	164	159	149	139	139
K, mEq/L [range: 3.5–5.1]	5.3	4.2	4.1	4.1	4.2	4.5
AST, U/L [range: 05–34]	34	47	57	34	34	56
ALT, U/L [range: 00–55]	19	28	33	30	28	43
CRP, mg/ml [range: < 0.5]	17.6	19.8	9.71	14.10	17.90	14.29	4.03

HbA1c—13.0 %
Dengue Rapid: NS1 negative; Dengue IgM negative; Dengue IgG positive
SARS-CoV-2 rRT-PCR positive
Na: Sodium, K: Potassium, AST: Aspartate Transaminase, ALT: Alanine Transaminase, CRP: c-reactive protein, HbA1c: Glycosylated hemoglobin, NS1: nonstructural protein 1, SARS-CoV-2 rRT-PCR: severe acute respiratory syndrome Coronavirus 2 recombinant reverse transcriptase polymerase chain reaction

Table 2. Laboratory investigations in case 2
Hemoglobin g/dl [range: 14–18]	11.3	11.4	10.5	9.1	11	9.2
Hematocrit, % [range: 40–54]	34	30	33	28	34.2	27
Leukocytes, 10³/ml [range: 5.0–10.0]	8.37	7.71	14.7	15.5	11.2	11.0
Neutrophils, % [range: 45–74]	70.1	63.4	91.7	93	82.2	80
Lymphocytes, % [range: 16–45]	16.0	21.9	3.9	4.7	13.2	11.1
Platelets, 10³/ml [range: 150–450]	174	180	240	179	180	176
Urea, mg/dl [range: 19–44.1]	59.9	44.9	64.2	59.9	29.96
Creatinine, mg/dl [range: 0.8–1.25]	1.48	1.22	1.77	1.28	0.69
Na, mEq/L [range: 135–145]	133	133	167	148	140	138
K, mEq/L [range: 3.5–5.1]	4.8	4.4	4.2	4.7	4.5	3.5
AST, U/l [range: 05–34]	23	26	22
ALT, U/l [range: 00–55]	15	17	21
CRP, mg/ml [range: < 0.5]	0.37	0.68	5.94	1.08	1.94	0.37

HbA1c—6.6 %
SARS-CoV-2 rRT-PCR positive
Na: Sodium, K: Potassium, AST: Aspartate Transaminase, ALT: Alanine Transaminase, CRP: c-reactive protein, HbA1c: Glycosylated hemoglobin, SARS-CoV-2 rRT-PCR: severe acute respiratory syndrome Coronavirus 2 recombinant reverse transcriptase polymerase chain reaction