The Peruvian Experience: New-Onset Diabetes Presenting With Diabetic Ketoacidosis in Patients With COVID19 Infections

Introduction: Data has emerged about patients with T2DM may experience DKA and HHS if infected with SARS-CoV-2. There is limited data about new-onset diabetes in patients with COVID-19. We describe a case series of three Peruvian patients with new onset diabetes presenting with DKA who remained insulin dependent several months after infection resolution. Case 1: A 59-year-old man with no significant past medical history and normal glucose presented with fever and dyspnea for five days. He was hospitalized with hypoxemic respiratory failure and tested positive forCOVID19. Hypoxemia improved with supportive care, but on day three, he became lethargic, tachycardic, and tachypneic with 95% oxygen saturation on room air. Biochemistry revealed an anion gap metabolic acidosis with pH 7.3, bicarbonate 10 mmol/L (22–28), β-hydroxybutyrate 5.4 mmol/L (<0.5), and glucose 679 mg/dL. He was treated with continuous insulin infusion. After DKA resolved, he was transitioned to basal-bolus insulin and remained insulin-dependent during outpatient follow-up. Case 2: A 49-year-old man in good health prior to admission, was transferred to our hospital for acute respiratory failure and positive testing for SARS-CoV-2. Two days later he became confused, tachycardic, and tachypneic with 90% oxygen saturation. DKA was diagnosed based on a pH 7.1, bicarbonate 8 mmol/L, β-hydroxybutyrate 5 mmol/L and glucose 625 mg/dL. He was transferred to the ICU for continuous insulin infusion. After resolution of his DKA, subcutaneous insulin was started. Preadmission hemoglobin A1c was 4.5%. He remained on insulin post hospital discharge. Case 3: A 33-year-old man with normal glucose prior to admission was transferred to our hospital from an outpatient office with a two-day history of dyspnea and altered sensorium. He was tachycardic and tachypneic with 96% oxygen saturation on 3L nasal cannula. He tested positive for SARS-CoV-2. DKA was diagnosed with glucose 690 mg/dL, bicarbonate 4 mmol/L, serum β-hydroxybutyrate 5.8 mmol/L and pH 6.6. He was resuscitated with intravenous fluids and an insulin infusion was started. DKA resolved after 5 days and he was discharged home on subcutaneous insulin. He remained insulin-dependent on follow-up. Conclusion: New-onset diabetes with DKA due to SARS-CoV-2 is increasingly recognized, and beta-cell dysfunction can be permanent, resulting in insulin-dependent diabetes. Accordingly, our patients remained insulin-dependent several months post discharge.