Diabetic Ketoacidosis Precipitated by COVID-19 in Patients Without Respiratory Symptoms: Case Reports

Diabetic ketoacidosis (DKA) is a life-threatening metabolic derangement, defined by the presence of severe hyperglycaemia, ketosis and metabolic acidosis. Recently, DKA was redefined to be present when the latter two abnormalities occur without severe hyperglycaemia. Munro and colleagues in Edinburgh described ‘euglycaemic diabetic ketoacidosis’ in 1973 and suggested this new terminology. The same year the critical feature of this subclass of DKA – that is, an increased urinary loss of glucose – was identified by Ireland and Thomson in Glasgow. In the subsequent 40 years (from 1974 to 2014), clinical interest in this condition was limited to a few case reports. The emergence of a new class of antidiabetes medications, the sodium-glucose cotransporter (SGLT) inhibitors, which promote profuse glycosuria, has reawakened interest in euglycaemic DKA, as this is a side effect of these drugs. The earlier perceptive observations of these physicians in Scotland deserve to be recognised for their contribution in identifying and describing euglycaemic DKA and correctly identifying its underlying pathogenesis. Recent international consensus has provided guidance to physicians to aid timely recognition of the condition by testing for ketosis in the appropriate clinical context and to manage it effectively by discontinuing the SGLT inhibitor and provision of insulin, carbohydrate and hydration (the STICH protocol). This may be particularly relevant in view of the recent licensing developments for use of certain members of the SGLT inhibitors in type 1 diabetes.

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Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature

Case Reports in Critical Care ◽

10.1155/2019/8769714 ◽

2019 ◽

Vol 2019 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Johnny F. Jaber ◽

Matthew Standley ◽

Raju Reddy

Keyword(s):

Blood Glucose ◽

Diabetic Ketoacidosis ◽

Case Reports ◽

Anion Gap ◽

Fetal Mortality ◽

Glucose Levels ◽

Elevated Glucose ◽

High Doses ◽

Euglycemic Diabetic Ketoacidosis ◽

In Pregnancy

Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose <200 mg/dL). Initial laboratory testing revealed a severe anion gap acidosis with pH 7.11, anion gap 23, elevated β-hydroxybutyric acid of 9.60 mmol/L, and a blood glucose of 183 mg/dL—surprisingly low given her severe acidosis. The ketoacidosis persisted despite high doses of glucose and insulin infusions. Due to nonresolving acidosis, her hospital course was complicated by spontaneous intrauterine fetal demise. Euglycemia and severe acidosis continued to persist until delivery of fetus and placenta occurred. It was observed that the insulin sensitivity dramatically increased after delivery of fetus and placenta leading to rapid correction of ketoacidosis. This case highlights that severe ketonemia can occur despite the absence of severely elevated glucose levels. We discuss the mechanism that leads to this pathophysiologic state and summarize previously published case reports about euglycemic DKA in pregnancy.

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345. Acute Onset Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic State in Patients Taking Integrase Strand Transfer Inhibitors

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.418 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S183-S184 ◽

Cited By ~ 1

Author(s):

Afua Duker Ntem-Mensah ◽

Nina Millman ◽

Niyati Jakharia ◽

Amanda Theppote ◽

Mona-Gekanju Toeque ◽

...

Keyword(s):

Weight Gain ◽

Blood Glucose ◽

Blood Glucose Level ◽

Diabetic Ketoacidosis ◽

Glucose Level ◽

Case Reports ◽

Acute Onset ◽

Anion Gap ◽

Hyperosmolar Hyperglycemic State ◽

Hba1c Levels

Abstract Background A few case reports have noted uncontrolled hyperglycemia in patients switched to dolutegravir. Several cohort studies have found increased weight gain among patients treated with integrase inhibitors (INSTI). We present clinical observations among 3 patients admitted to hospital for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) while receiving INSTIs for the management of HIV. Methods Case 1: A 44-year-old man with HIV and dyslipidemia presented with altered mental status and lethargy. A fingerstick glucose was >600 mg/dL. Chemistries revealed glucose of 1,600 mg/dL and an elevated β-hydroxybutyrate. HbA1c was 12.4%. His antiretroviral regimen consisted of cEVG/TAF/FTC for the last 3 years. Previous HbA1c levels were 5.7% and 6.2% (Figure 1). Case 2: A 55-year-old woman with HIV, hypertension, dyslipidemia, and obesity presented with polyuria and polydipsia. The blood glucose level was >1,200 mg/dL with an anion gap >30 and HbA1c of 15%. Previous HbA1c levels ranged between 5.6 and 5.8% (Figure 2). She had been taking ABC/FTC/DTG for 2 years. Case 3: A 64 yo man with a history of HIV, hypertension, and obesity presented with polyuria and polydipsia. The blood glucose level was 1,152 mg/dL with no anion gap and HbA1c of 13.4%. Six months before, he had been switched from a c/DRV- based ART regimen to ABC/FTC/DTG. Previous HbA1c levels ranged between 5.8% and 6.2% (Figure 3). Results Discussion: In the first 2 patients, the presentation with acute onset DKA occurred more than a year after being on an INSTI-based regimen; however, the latter patient presented with HHS within 6 months of being switched to an INSTI-containing regimen. The mechanism of action of INSTIs causing weight gain or an association with hyperglycemia is still under investigation. Conclusion Although the temporal onset of DKA and HHS while receiving INSTIs was not precise, the possible association of INSTIs and their direct effects on insulin resistance and diabetes warrant additional attention from post-market data. Meanwhile, providers should monitor INSTI-treated patients closely, especially those with features of metabolic syndrome. Disclosures All authors: No reported disclosures.

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Euglycemic Diabetic Ketoacidosis Associated With Sodium–Glucose Cotransporter Type 2 Inhibitors in Patients With Type 2 Diabetes Mellitus Receiving Oral Therapy

Journal of Pharmacy Practice ◽

10.1177/0897190017748049 ◽

2017 ◽

Vol 32 (2) ◽

pp. 240-243 ◽

Cited By ~ 3

Author(s):

Ryan B. Dull ◽

Mikayla L. Spangler ◽

Emily L. Knezevich ◽

Britney M. Lau

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Diabetic Ketoacidosis ◽

Case Reports ◽

Serious Adverse Events ◽

Type 2 Dm ◽

Sodium Glucose Cotransporter ◽

Increased Risk

Introduction and Objective: Postmarketing reports and warnings of serious adverse events such as diabetic ketoacidosis (DKA) have raised concern regarding the safety of sodium–glucose cotransporter 2 inhibitors (SGLT2i). This report describes 2 cases of symptomatic SGLT2i-associated euglycemic DKA (euDKA) leading to hospitalization in patients with type 2 diabetes mellitus (DM) previously well controlled on oral medications. Case Reports: Subject 1 is a 55-year-old female admitted with euDKA precipitated by infection and managed with intravenous insulin. This case was notable for a delayed diagnosis of euDKA and lack of clinical improvement despite withholding dapagliflozin. Subject 2 is a 62-year-old male admitted with euDKA precipitated by infection. His clinical condition improved rapidly and euDKA responded to withdrawal of empagliflozin alone. Discussion: Applying the Naranjo adverse medication reaction probability scale to each case (subject 1 score = 3 points; subject 2 score = 4 points) suggests these are possible adverse reactions to SGLT2i. Data from randomized controlled trials suggest DKA events in adults with type 2 DM receiving SGLT2i are rare and similar to placebo. However, data from a large cohort suggest these events occur more frequently and are associated with a 2-fold increased risk of DKA. Conclusion: This class of medications may be associated with a higher real-world risk of DKA in adults with type 2 DM than previously reported. Patients prescribed these medications should receive vigilant assessment for features of traditional DKA as well as euDKA.

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Spontaneous muscle hematoma in older patients with COVID-19: two case reports and literature review

BMC Geriatrics ◽

10.1186/s12877-020-01963-4 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Sara Rogani ◽

Valeria Calsolaro ◽

Riccardo Franchi ◽

Alessia Maria Calabrese ◽

Chukwuma Okoye ◽

...

Keyword(s):

Literature Review ◽

Older Patients ◽

Respiratory Symptoms ◽

Distress Syndrome ◽

Case Reports ◽

Coagulation System ◽

Blood Tests ◽

Hemorrhagic Complications ◽

History Of ◽

Caucasian Female

Abstract Background In late December 2019, a cluster of pneumonia cases due to a novel betacoronavirus, SARS-CoV-2 was reported in China. The so-called COVID 19 is responsible not only for respiratory symptoms, from mild up to pneumonia and even acute respiratory distress syndrome, but also for extrapulmonary involvement. Cases presentation Here we present two cases of spontaneous muscle hematoma in patients with SARS-CoV-2 infection, both on therapeutic LMWH for atrial fibrillation: the first one was an 86-year-old Caucasian female with a history of hypertensive cardiomyopathy and the second one was an 81-year-old Caucasian male with a history of hypertension, diabetes and ischemic heart disease. Blood tests revealed a considerable drop of hemoglobin and alterations of coagulation system. In both cases, embolization of femoral artery was performed. A few other cases of bleeding manifestations are reported in literature, while a lot has been published about the hypercoagulability related to COVID-19. Conclusions Our reports and literature review highlight the need of active surveillance for possible hemorrhagic complications in patients with SARS-CoV-2 infection.

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Diabetic ketoacidosis in the dialysis-dependent patient: two case reports and recommendations for treatment

CJEM ◽

10.1017/s1481803500009271 ◽

2004 ◽

Vol 6 (04) ◽

pp. 281-284 ◽

Cited By ~ 5

Author(s):

Jamie Blicker ◽

Anthony M. Herd ◽

Joanne Talbot

Keyword(s):

Diabetic Ketoacidosis ◽

Case Reports ◽

Dependent Patient

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Diabetic Ketoacidosis as First Presentation of Latent Autoimmune Diabetes in Adult

Case Reports in Medicine ◽

10.1155/2015/821397 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Omar Nadhem ◽

Essam Nakhla ◽

Roger D. Smalligan

Keyword(s):

Diabetic Ketoacidosis ◽

Age Of Onset ◽

Autoimmune Diabetes ◽

Case Reports ◽

White Female ◽

Acid Decarboxylase ◽

Insulin Independence ◽

Adult Age ◽

Latent Autoimmune Diabetes ◽

Diabetic Education

A 54-year-old white female with hypothyroidism presented with abdominal pain, nausea, vomiting, and diarrhea. She was found to have diabetic ketoacidosis (DKA) and admitted to our hospital for treatment. Laboratory workup revealed positive antiglutamic acid decarboxylase antibodies and subsequently she was diagnosed with latent onset autoimmune diabetes in adult (LADA). She was successfully treated with insulin with clinical and laboratory improvement. Diagnosis of LADA has been based on three criteria as given by The Immunology of Diabetes Society: (1) adult age of onset (>30 years of age); (2) presence of at least one circulating autoantibody (GADA/ICA/IAA/IA-2); and (3) initial insulin independence for the first six months. The importance of this case is the unlikely presentation of LADA. We believe that more research is needed to determine the exact proportion of LADA patients who first present with DKA, since similar cases have only been seen in case reports. Adult patients who are obese and have high blood sugar may deserve screening for LADA, especially in the presence of other autoimmune diseases. Those patients once diagnosed with LADA need extensive diabetic education including potentially serious events such as diabetic ketoacidosis.

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Extrapulmonary manifestations and complications of severe acute respiratory syndrome coronavirus 2 infection: a systematic review

Singapore Medical Journal ◽

10.11622/smedj.2021100 ◽

2021 ◽

Author(s):

J Cho ◽

J Lee ◽

CH Sia ◽

CS Koo ◽

BYQ Tan ◽

...

Keyword(s):

Severe Acute Respiratory Syndrome ◽

Respiratory Symptoms ◽

Case Reports ◽

Meta Analysis ◽

Severe Disease ◽

Late Phase ◽

Cardiac Injury ◽

Gastrointestinal Symptoms ◽

Case Series ◽

Venous Thromboembolic Events

Introduction: We aimed to describe the extrapulmonary manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, including their frequency, onset with respect to respiratory symptoms, pathogenesis and association with disease severity. Methods: We searched the MEDLINE and Embase databases for SARS-CoV-2-related studies. Meta-analysis, observational studies, case series and case reports published in English or Chinese between 1 January and 1 May 2020 were included. Reports with only paediatric or obstetric cases were excluded. Results: 169 articles were included. Early manifestations (preceding respiratory symptoms until Day 6 of onset) included olfactory and gustatory disturbance (self-reported in up to 68% and 85% of cases, respectively), gastrointestinal symptoms (up to 65.9%) and rash (up to 20.4%). From Day 7 onwards, hypercytokinaemia, paralleled multi-organ complications including acute cardiac injury (pooled incidence of 17.7% in 1,412 patients, mostly with severe disease and 17.4% mortality), kidney and liver injury (up to 17% and 33%, respectively) and thrombocytopenia (up to 30%). Hypercoagulability resulted in venous thromboembolic events in up to 31% of all patients. Uncommon disease presentation and complications comprised Guillain-Barré syndrome, rhabdomyolysis, otitis media, meningoencephalitis and spontaneous pneumomediastinum. Conclusion: Although the systemic manifestations of SARS-CoV-2 infection are variegated, they are deeply interwoven by shared mechanisms. Two phases of extrapulmonary disease were identified: (a) an early phase with possible gastrointestinal, ocular and cutaneous involvement and (b) a late phase characterised by multiorgan dysfunction and clinical deterioration. A clear, multidisciplinary consensus to define and approach thromboinflammation and cytokine release syndrome in SARS-CoV-2 is needed.

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Diagnosing Bird Fancier's Disease in Children

PEDIATRICS ◽

10.1542/peds.85.5.848 ◽

1990 ◽

Vol 85 (5) ◽

pp. 848-852

Author(s):

WILLIAM F. H. YEE ◽

ROBERT G. CASTILE ◽

AMIEL COOPER ◽

MARY ROBERTS ◽

ROY PATTERSON

Keyword(s):

Weight Loss ◽

Environmental History ◽

Respiratory Symptoms ◽

Hypersensitivity Pneumonitis ◽

Case Reports ◽

Low Grade ◽

Poor Appetite ◽

The Family ◽

History Of ◽

Respiratory Complaints

Bird fancier's disease is a form of hypersensitivity pneumonitis resulting from inhalation of various avian proteins. It is rarely diagnosed in childhood but should be considered in any child with persistent unexplained respiratory symptoms.1,2 We describe two patients referred to our pulmonary clinic with nonspecific respiratory complaints, in whom the diagnosis of avian protein-related hypersensitivity pneumonitis was initially not confirmed by serologic studies. CASE REPORTS Patient 1 An 11-year-old boy was admitted to the hospital with a 1-year history of a mild nonproductive cough, poor appetite, weight loss, malaise, and an intermittent low-grade fever. According to an environmental history, the boy's father had been breeding pigeons, canaries, and parakeets in the family yard for years.

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