Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

Introduction Several studies have described typical clinical manifestations, including fever, cough, diarrhea, and fatigue with COVID-19 infection. However, there are limited data on the association between the presence of neurological manifestations on hospital admission, disease severity, and outcomes. We sought to investigate this correlation to help understand the disease burden. Methods We delivered a multi-center retrospective study of positive laboratory-confirmed COVID-19 patients. Clinical presentation, laboratory values, complications, and outcomes data were reported. Our findings of interest were Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and in-hospital mortality. Results A total of 502 patients with a mean age of 60.83 ± 15.5 years, of them 71 patients (14.14%) presented with altered mental status, these patients showed higher odds of ICU admission (OR = 2.06, 95%CI = 1.18 to 3.59, p = 0.01), mechanical ventilation (OR = 3.28, 95%CI = 1.86 to 5.78, p < 0.001), prolonged (>4 days) mechanical ventilation (OR = 4.35, 95%CI = 1.89 to 10, p = 0.001), acute kidney injury (OR = 2.18, 95%CI = 1.28 to 3.74, p = 0.004), and mortality (HR = 2.82, 95%CI = 1.49 to 5.29, p = 0.01). Conclusion This cohort study found that neurological presentations are associated with higher odds of adverse events. When examining patients with neurological manifestations, clinicians should suspect COVID-19 to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

Download Full-text

Incidence and Outcomes of Acute Kidney Injury in Patients Admitted to Hospital With COVID-19: A Retrospective Cohort Study

Canadian Journal of Kidney Health and Disease ◽

10.1177/20543581211027759 ◽

2021 ◽

Vol 8 ◽

pp. 205435812110277

Author(s):

Tyler Pitre ◽

Angela (Hong Tian) Dong ◽

Aaron Jones ◽

Jessica Kapralik ◽

Sonya Cui ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Kidney Injury ◽

Cohort Study ◽

Hospital Mortality ◽

Disease Severity ◽

Retrospective Cohort Study ◽

Odds Ratio ◽

Retrospective Cohort ◽

Kidney Injury ◽

Icu Admission

Background: The incidence of acute kidney injury (AKI) in patients with COVID-19 and its association with mortality and disease severity is understudied in the Canadian population. Objective: To determine the incidence of AKI in a cohort of patients with COVID-19 admitted to medicine and intensive care unit (ICU) wards, its association with in-hospital mortality, and disease severity. Our aim was to stratify these outcomes by out-of-hospital AKI and in-hospital AKI. Design: Retrospective cohort study from a registry of patients with COVID-19. Setting: Three community and 3 academic hospitals. Patients: A total of 815 patients admitted to hospital with COVID-19 between March 4, 2020, and April 23, 2021. Measurements: Stage of AKI, ICU admission, mechanical ventilation, and in-hospital mortality. Methods: We classified AKI by comparing highest to lowest recorded serum creatinine in hospital and staged AKI based on the Kidney Disease: Improving Global Outcomes (KDIGO) system. We calculated the unadjusted and adjusted odds ratio for the stage of AKI and the outcomes of ICU admission, mechanical ventilation, and in-hospital mortality. Results: Of the 815 patients registered, 439 (53.9%) developed AKI, 253 (57.6%) presented with AKI, and 186 (42.4%) developed AKI in-hospital. The odds of ICU admission, mechanical ventilation, and death increased as the AKI stage worsened. Stage 3 AKI that occurred during hospitalization increased the odds of death (odds ratio [OR] = 7.87 [4.35, 14.23]). Stage 3 AKI that occurred prior to hospitalization carried an increased odds of death (OR = 5.28 [2.60, 10.73]). Limitations: Observational study with small sample size limits precision of estimates. Lack of nonhospitalized patients with COVID-19 and hospitalized patients without COVID-19 as controls limits causal inferences. Conclusions: Acute kidney injury, whether it occurs prior to or after hospitalization, is associated with a high risk of poor outcomes in patients with COVID-19. Routine assessment of kidney function in patients with COVID-19 may improve risk stratification. Trial registration: The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

Download Full-text

Altered Mental Status and Cyanosis in a Pediatric Patient with Methemoglobinemia

Case Reports in Pediatrics ◽

10.1155/2020/8896754 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Phillip M. Grenz ◽

Robert N. Ray Jr. ◽

Olivia A. Hardy ◽

Andrew L. Koons ◽

Kenneth D. Katz ◽

...

Keyword(s):

Mental Status ◽

Clinical Manifestations ◽

Altered Mental Status ◽

Pediatric Emergency ◽

Abrupt Onset ◽

Altered Level ◽

Sustained Improvement ◽

Oxygen Dissociation ◽

Nail Polish ◽

Level Of Consciousness

Methemoglobinemia results from increased amounts of oxidized hemoglobin in the blood with an ensuing change in oxygen dissociation curve and lack of oxygen delivery to tissue. A previously well, male toddler was brought to the Pediatric Emergency Department (PED) by Emergency Medical Services (EMS) with abrupt onset of altered mental status and cyanosis after a suspected ingestion of “Rush” nail polish remover. He was quickly diagnosed with methemoglobinemia by both clinical presentation and chocolate-colored blood appearance. He emergently received intravenous (IV) methylene blue (MB) with immediate and sustained improvement requiring no further doses. Though inhalation of nitrites and subsequent methemoglobinemia is frequently reported in adolescents, we were unable to find any cases in the literature detailing ingestion of this product and the resulting clinical manifestations. Our objective with this report is to describe a rare case of a toddler with an accidental ingestion of “Rush” nail polish remover, a nitrite compound. Our patient presented to the PED with abrupt onset of altered level of consciousness, hypotension, and cyanosis resulting from acquired methemoglobinemia. This case report demonstrates the importance of emergency clinicians being able to make clinical judgements and decisions based on the history and physical exam when methemoglobinemia is suspected.

Download Full-text

189. Bacteremia among COVID-19 and Non-Covid-19 Patients Admitted in the ICU

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.391 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S203-S203

Author(s):

paraskeui chra ◽

Evdokia Gavrielatou ◽

prodromos Temperikidis ◽

Michalis Tsimaras ◽

eleni magira

Keyword(s):

Mechanical Ventilation ◽

Cohort Study ◽

Retrospective Cohort ◽

Bloodstream Infections ◽

Apache Ii Score ◽

Drug Resistant ◽

Icu Admission ◽

Critical Patients ◽

Underlying Diseases ◽

Diabetes And Obesity

Abstract Background The aim of this work were to investigate the rate and aetiology of bloodstream infection collected from COVID and non-COVID patients admitted in the ICU Methods A retrospective cohort study was conducted on PCR Covid-19 positive patients admitted in the ICU from 20th March to 30th April 2020. Corresponding data from the same period in 2019 collected of all consecutive patients admitted in the same ICU were retrospectively reviewed for the presence of microbiologically documented bloodstream infections at least 8 hours after admission. All patients in the cohort study were on mechanical ventilation, or at some point during their ICU admission required mechanical ventilation. Results We identified a total of 19 (38%) BSIs in the COVID-19 group and 10 (12%) BSI in the non-COVID-19 group (p=0,8). COVID-19 patients had an increased probability to develop ICU-BSI, at a median of 8 days of ICU admission as opposed to 6 in the non-COVID-19 group. Patients were comparable in terms of age, and APACHE II score. Out of 19 BSI CoVID-19 patients, 14 (73%) were male vs 5 (50%) in the non-CoVID-19 BSI patients (p=0.0007). Of all BSI-CoVID-19 patients, 7 cases (37%), 3 (16%), and 3(16%) had underlying diseases such as hypertension, diabetes, and obesity vs 1(9%), 0(0%), and 0 (0%) in the BSI-non CoVID-19 patients statistically significant at p=0.004, p=0.05, and p=0.05, respectively. ICU-acquired BSIs were mostly due to multi-drug-resistant pathogens. Clinical outcomes were statistically significantly different between patients with CoVid-19 BSI 7(37% ) and 2(20%)in BSI- non-CoVID-19 pneumonia (p=0.02). Conclusion Our findings emphasize that although the incidence of BSI in CoVID-19 positive ICU admitted patients slightly increased their impact on overall outcome was significantly worse. Consequently, it is important to pay attention to bacterial superinfections in critical patients positive for COVID-19. Disclosures All Authors: No reported disclosures

Download Full-text

MON-LB65 Lithium: The Culprit of Multiple Endocrinopathies

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.2227 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Alice Yau ◽

Gul Bahtiyar ◽

Giovanna Rodriguez ◽

Jose R Martinez Escudero

Keyword(s):

Bipolar Disorder ◽

Diabetes Insipidus ◽

Mental Status ◽

Nephrogenic Diabetes Insipidus ◽

Kidney Injury ◽

Urine Osmolality ◽

Altered Mental Status ◽

Clinical Findings ◽

Volume Depletion ◽

Collecting Tubules

Abstract Background: Lithium, commonly used to treat various psychiatric disorders such as bipolar disorder, can cause acute toxicity that presents with nausea, vomiting and diarrhea. Lithium can also cause life-threatening endocrine abnormalities, including hypercalcemia, hypernatremia, and both hypo- and hyperthyroidism. Clinical Case: A 61-year old female with hypothyroidism, bipolar disorder, hyperparathyroidism with two-gland parathyroidectomy on lithium for over 30 years presented with altered mental status. Initial labs revealed elevated creatinine 1.92 mg/dL (0.8-2.00mg/dL) compared to baseline 0.82 mg/dL, sodium 154 mg/dL (135-147 mg/dL), Corrected calcium 11.7 mg/dL (8.5-10.5 mg/dL), PTH 96 pg/mL (15-65 pg/mL), and high lithium levels 1.45 mmol/L (0.60-1.20 mmol/L). Further studies showed hypotonic polyuria with no increase in urine osmolality after desmopressin, consistent with nephrogenic diabetes insipidus. Lithium was held and she was treated with aggressive intravenous hydration with dextrose 5% water. Hypercalcemia is thought to result from increased secretion of PTH due to an increased set point at which calcium suppresses PTH release; this often resolves once lithium is stopped. Lithium can also unmask previously unrecognized mild hyperparathyroidism, and/or raise serum PTH concentrations independent of calcium levels.1 The drug interferes with the kidneys’ ability to concentrate urine in the collecting tubules by desensitizing response to antidiuretic hormone, causing diabetes insipidus. The resulting volume depletion from excessive urinary water loss in turn lead to acute kidney injury and hypernatremia.2 Hypothyroidism results from lithium-inhibited synthesis and release of thyroid hormones and decreases iodine trapping. Conclusion: Although these are infrequent complications of lithium use, they remain pertinent clinical findings to consider due to their morbidity. In this case, our patient may have avoided multiple chronic electrolyte abnormalities leading to altered mental status if lithium toxicity had been recognized earlier. References:1. García-Maldonado, Gerardo, and Rubén de Jesús Castro-García. “Endocrinological Disorders Related To The Medical Use Of Lithium. A Narrative Review”. Revista Colombiana De Psiquiatría (English Ed.), vol 48, no. 1, 2019, pp. 35-43. Elsevier BV, doi:10.1016/j.rcpeng.2018.12.005. 2. Tasci, E. “Lithium-Induced Nephrogenic Diabetes Insipidus Responsive To Desmopressin”. Acta Endocrinologica (Bucharest), vol 15, no. 2, 2019, pp. 270-271. ACTA Endocrinologica Foundation, doi:10.4183/aeb.2019.270.

Download Full-text

Acute kidney injury and major outcomes in cancer patients with no history of chronic kidney disease (CKD) with coronavirus 2019 (COVID-19) infection.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18816 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18816-e18816

Author(s):

Cesar Simbaqueba ◽

Omar Mamlouk ◽

Kodwo Dickson ◽

Josiah Halm ◽

Sreedhar Mandayam ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Kidney Injury ◽

Cancer Patients ◽

Clinical Outcomes ◽

Kidney Injury ◽

Hazard Model ◽

Cancer Center ◽

Icu Admission ◽

Significant Difference ◽

History Of

e18816 Background: Acute Kidney Injury (AKI) in patients with COVID-19 infection is associated with poor clinical outcomes. We examined outcomes (hemodialysis, mechanical ventilation, ICU admission and death) in cancer patients with normal estimated glomerular filtration rate (eGFR) treated in a tertiary referral center with COVID-19 infection, who developed AKI within 30 days of diagnosis. Methods: All patient data — demographics, labs, comorbidities and outcomes — were aggregated and analyzed in the Syntropy platform, Palantir Foundry (“Foundry”), as part of the Data-Driven Determinants of COVID-19 Oncology Discovery Effort (D3CODE) protocol at MD Anderson. The cohort was defined by the following: (1) positive COVID-19 test; (2) baseline eGFR >60 ml/min/1.73m2most temporally proximal lab results within 30 days prior to the patient’s infection. AKI was defined by an absolute change of creatinine ≥0.3 within 30 days after the positive COVID-19 test. Kaplan-Meier analysis was used for survival estimates at specific time periods and multivariate Cox Proportional cause-specific Hazard model regression to determine hazard ratios with 95% confidence intervals for major outcomes. Results: 635 patients with Covid-19 infection had a baseline eGFR >60 ml/min/1.73m2. Of these patients, 124 (19.5%) developed AKI. Patients with AKI were older, mean age of 61+/-13.2 vs 56.9+/- 14.3 years (p=0.002) and more Hypertensive (69.4% vs 56.4%, p=0.011). AKI patients were more likely to have pneumonia (63.7% vs 37%, p<0.001), cardiac arrhythmias (39.5% vs 20.7%, p<0.001) and myocardial infarction (15.3% vs 8.8%, p=0.046). These patients had more hematologic malignancies (35.1% vs 19%, p=0.005), with no difference between non metastatic vs metastatic disease (p=0.284). There was no significant difference in other comorbidities including smoking, diabetes, hypothyroidism and liver disease. AKI patients were more likely to require dialysis (2.4% vs 0.2%, p=0.025), mechanical ventilation (16.1% vs 1.8%, p<0.001), ICU admission (43.5% vs 11.5%, p<0.001) within 30 days, and had a higher mortality at 90 days of admission (20.2% vs 3.7%, p<0.001). Multivariate Cox Proportional cause-specific Hazard model regression analysis identified history of Diabetes Mellitus (HR 10.8, CI 2.42 - 48.4, p=0.001) as an independent risk factor associated with worse outcomes. Mortality was higher in patients with COVID-19 infection that developed AKI compared with those who did not developed AKI (survival estimate 150 days vs 240 days, p=0.0076). Conclusions: In cancer patients treated at a tertiary cancer center with COVID-19 infection and no history of CKD, the presence of AKI is associated with worse outcomes including higher 90 day mortality, ICU stay and mechanical ventilation. Older age and hypertension are major risk factors, where being diabetic was associated with worse clinical outcomes.

Download Full-text

Combined anticoagulant and antiplatelet therapy is associated with an improved outcome in hospitalised patients with COVID-19: a propensity matched cohort study

Open Heart ◽

10.1136/openhrt-2021-001785 ◽

2021 ◽

Vol 8 (2) ◽

pp. e001785

Author(s):

Kamal Matli ◽

Nibal Chamoun ◽

Aya Fares ◽

Victor Zibara ◽

Soad Al-Osta ◽

...

Keyword(s):

Mechanical Ventilation ◽

Cohort Study ◽

Hospital Mortality ◽

Primary Outcome ◽

Icu Admission ◽

Therapeutic Anticoagulation ◽

Hospitalised Patients ◽

Significant Difference ◽

Prophylactic Anticoagulation ◽

Improved Outcome

BackgroundCOVID-19 is a respiratory disease that results in a prothrombotic state manifesting as thrombotic, microthrombotic and thromboembolic events. As a result, several antithrombotic modalities have been implicated in the treatment of this disease. This study aimed to identify if therapeutic anticoagulation (TAC) or concurrent use of antiplatelet and anticoagulants was associated with an improved outcome in this patient population.MethodsA retrospective observational cohort study of adult patients admitted to a single university hospital for COVID-19 infection was performed. The primary outcome was a composite of in-hospital mortality, intensive care unit (ICU) admission or the need for mechanical ventilation. The secondary outcomes were each of the components of the primary outcome, in-hospital mortality, ICU admission, or the need for mechanical ventilation.Results242 patients were included in the study and divided into four subgroups: Therapeutic anticoagulation (TAC), prophylactic anticoagulation+antiplatelet (PACAP), TAC+antiplatelet (TACAP) and prophylactic anticoagulation (PAC) which was the reference for comparison. Multivariable Cox regression analysis and propensity matching were done and showed when compared with PAC, TACAP and TAC were associated with less in-hospital all-cause mortality with an adjusted HR (aHR) of 0.113 (95% CI 0.028 to 0.449) and 0.126 (95% CI 0.028 to 0.528), respectively. The number needed to treat in both subgroups was 11. Furthermore, PACAP was associated with a reduced risk of invasive mechanical ventilation with an aHR of 0.07 (95% CI 0.014 to 0.351). However, the was no statistically significant difference in the occurrence of major or minor bleeds, ICU admission or the composite outcome of in-hospital mortality, ICU admission or the need for mechanical ventilation.ConclusionThe use of combined anticoagulant and antiplatelet agents or TAC alone in hospitalised patients with COVID-19 was associated with a better outcome in comparison to PAC alone without an increase in the risk of major and minor bleeds. Sufficiently powered randomised controlled trials are needed to further evaluate the safety and efficacy of combining antiplatelet and anticoagulants agents or using TAC in the management of patients with COVID-19 infection.

Download Full-text

Neurotoxicity after high-dose melphalan.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.6546 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 6546-6546 ◽

Cited By ~ 1

Author(s):

Jose Eugenio Najera ◽

Tummala Sudhakar ◽

Qaiser Bashir ◽

Nina Shah ◽

Richard E. Champlin ◽

...

Keyword(s):

Mental Status ◽

Epileptiform Activity ◽

Clinical Manifestations ◽

Altered Mental Status ◽

Cancer Center ◽

High Dose ◽

Loss Of Consciousness ◽

Hematopoietic Stem ◽

Neurologic Recovery ◽

High Dose Melphalan

6546 Background: High dose melphalan (HDM) at 200 mg/m2 is the standard preparative regimen for patients with multiple myeloma (MM) and light-chain amyloidosis (AL) undergoing autologous hematopoietic stem cell transplantation (auto-HCT). Neurotoxicity has been seen with HDM. In this report we describe the incidence, clinical manifestations and outcome of HDM- associated neurotoxicity. Methods: We performed a chart review of all patients who received HDM and auto-HCT for MM or AL between January 2007 to December 2009 at the University of Texas MD Anderson Cancer Center (MDACC). HDM- associated encephalopathy was defined as altered mental status, seizure or unexplained loss of consciousness within 30 days of auto-HCT. Patients with documented hemorrhagic or embolic stroke, or metabolic abnormalities were excluded. Results: 451 patients were included. Median age at auto-HCT was 59 years (range: 35-80). Thirty patients (6.6%) had AL and 61 patients (13.5%) had a pre-transplant serum creatinine of > 1.5 mg/dl. Nine patients (2.0%) developed HDM-associated encephalopathy with a median of 13 days (range 4-22) from auto-HCT. Among patients with encephalopathy, 8 (89%) developed changes in mental status ranging from drowsiness and confusion to loss of consciousness, while one patient had tonic-clonic seizures (11%). Of the affected patients there were 6 (66%) females, 8 patients (89%) > 59 years of age and only 2 patients (22%) had a creatinine clearance of < 60 ml/min. One patient was dialysis-dependent. A CT scan or MRI was obtained in all 9 patients. Only one patient had imaging abnormalities reported as posterior reversible encephalopathy syndrome (PRES). Electroencephalogram (EEG) was performed on 6 patients. Epileptiform activity was seen in one patient with clinical seizures. Mild generalized slowing was noted in 2 other patients with mental status changes. Cerebrospinal fluid was obtained in 2 patients and did not show any abnormalities. Complete resolution of neurologic symptoms was seen in all patients prior to hospital discharge, and there were no deaths. Conclusions: HDM-induced encephalopathy was seen in only 2% patients, and it is associated with complete neurologic recovery without any increase in transplant-related mortality.

Download Full-text

Delayed diagnosis of odontogenic infection: a lesson from altered mental status and abnormal breathing

Oxford Medical Case Reports ◽

10.1093/omcr/omy079 ◽

2018 ◽

Vol 2018 (11) ◽

Author(s):

Ai Sawaoka ◽

Toshiki Ito ◽

Takayuki Yoshida ◽

Koichiro Muromachi ◽

Tomoko Sakai ◽

...

Keyword(s):

Mental Status ◽

Delayed Diagnosis ◽

Altered Mental Status ◽

Odontogenic Infection ◽

Abnormal Breathing

Download Full-text

Epidemiology and clinical outcomes of patients withFusobacteriumbacteraemia

Epidemiology and Infection ◽

10.1017/s0950268812000660 ◽

2012 ◽

Vol 141 (2) ◽

pp. 325-329 ◽

Cited By ~ 13

Author(s):

E. A. GOLDBERG ◽

T. VENKAT-RAMANI ◽

M. HEWIT ◽

H. F. BONILLA

Keyword(s):

Mental Status ◽

Clinical Laboratory ◽

Tertiary Care ◽

Length Of Hospital Stay ◽

Outcome Data ◽

Care Hospital ◽

Icu Admission ◽

The Usa ◽

Elevated Creatinine ◽

Poor Outcomes

SUMMARYThis 10-year retrospective study assessed the epidemiology and outcomes of patients withFusobacteriumbacteraemia (FB) at a tertiary-care hospital in the USA – this is the second study focusing on FB in adults to be conducted in the USA in 30 years. Demographic, clinical, laboratory, treatment, and outcome data were collected and statistically analysed. Nineteen patients with FB were identified, representing 0·11% of bacteraemia cases. Mean age was 58·6 years with equal gender distribution. Common comorbidities included cardiovascular disease (CVD) and immunosuppression. Thirty-day mortality was 21·1%, and 68·4% of FB patients required intensive care unit (ICU) admission. Elevated creatinine levels and mental status changes were associated with higher mortality (P = 0·0181 and 0·0374, respectively). CVD, diabetes, and ICU admission were associated with increased length of hospital stay (P = 0·0017, 0·0010, and 0·0379, respectively). The prevalence of FB at our hospital was very low, with poor outcomes associated with increased creatinine level, mental status changes, CVD, diabetes and ICU admission.

Download Full-text

COVID-19 and Combined Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Coma: Report of 11 Cases

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/23247096211021231 ◽

2021 ◽

Vol 9 ◽

pp. 232470962110212

Author(s):

Balraj Singh ◽

Parminder Kaur ◽

Nicole Majachani ◽

Prem Patel ◽

Ro-Jay Romor Reid ◽

...

Keyword(s):

Mechanical Ventilation ◽

Diabetic Ketoacidosis ◽

Case Series ◽

Kidney Injury ◽

Altered Mental Status ◽

Metabolic Complications ◽

Poor Prognostic Factor ◽

Vulnerable Patient ◽

Hyperglycemic Hyperosmolar Nonketotic Coma ◽

Type 1 Dm

We report 11 cases of combined diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNK) in coronavirus 2019 patients who presented to our institution in New Jersey, USA. The median age was 47 years (range 12-88 years). Out of the 11 patients, 7 were male and 4 were female. Out of 11 patients, 8 had type 2 diabetes mellitus (DM), 2 had undiagnosed DM, and 1 had type 1 DM. Presenting complaints included altered mental status, weakness, shortness of breath, cough, fever, vomiting, abdominal pain, chest pain, and foot pain. Out of 11 patients, pneumonia was diagnosed at presentation in 8 patients, while in 3 patients, chest X-ray was clear. Median value of initial glucose on presentation was 974 mg/dL (range 549-1556 mg/dL), and hemoglobin A1c on presentation was 13.8%. The median value of anion gap was 34 mEq/L. Out of the 11 patients, ketonemia was moderate in 6 patients, large in 3, and small in 2 patients. Acute kidney injury (AKI) occurred in 9 patients and 2 patients required renal replacement therapy. Out of the 11 patients, 6 required mechanical ventilation and 7 patients died. All the 6 patients requiring mechanical ventilation died. Our case series shows COVID-19 infection can precipitate acute metabolic complications in known DM patients or as first manifestation in undiagnosed DM patients. Patients can present with DKA/HHNK symptoms and/or respiratory symptoms. Mechanical ventilation is a poor prognostic factor. Further studies are needed to characterize prognostic factors associated with mortality in this vulnerable patient population.

Download Full-text