A Novel Case of Hyperinsulinemic Hypoglycemia in a Neonate With SARS-CoV-2 Infection

The Case: An 8 days old male, born at 40 wks, 2.8 kg (SGA) presented to local ED with lethargy, decreased PO intake and urine output, respiratory distress. No fever, URI sx, vomiting/diarrhea. His dad had URI symptoms and fever a week prior. He was found to have T=95.5F, glucose <10 mg/dL, improved to 125 after D10 boluses x2; and required supplemental O2 due to desats/cyanosis. CXR showed bilateral hazy opacities. Sepsis rule out was initiated, patient admitted to the PICU, started on antibiotics and dextrose. Patient became more alert over the next 3 days, but could not be weaned off from IV dextrose/continuous feeds, GIR up to 15 mg/kg/min. He was transferred to our institution. Critical sample at BG of 45 mg/dl showed high insulin level (6.9 uU/ml) and C-peptide (1.25 ng/dl); low beta-OH butyrate <0.2 mmol/L; and free fatty acids (0.25 mmol/L); all suggestive of hyerperinsulinemic hypoglycemia (HH). Cortisol and GH robust at 10.5 mcg/dl and 7.13 ng/ml. Nasopharyngeal swab for SARS-CoV-2 RT-PCR positive. Dad’s swab also positive. Mom was asymptomatic and not tested. ID was consulted, recommended supportive management and close observation. Pt was started on Diazoxide 10mg/kg/day divided q8h, and hydrochlorothiazide (HCT) 5mg/day. Patient’s status gradually improved - BG stabilized, feeds were compressed, IV fluids and O2 supplementation weaned off, and was discharged after 8 days with average BG in the 70-80’s range. Diazoxide and HCT were successfully weaned off in the following 3 mos. To this day patient remains well, no recurrence of hypoglycemia. Discussion/Conclusion: There is a dearth of information on SARS-CoV-2 infection in newborns. The few studies available show favorable outcomes in this population, with typical mild-moderate respiratory symptoms and fever, while some newborns are asymptomatic. Our patient required oxygen tx and developed HH requiring Diazoxide therapy. To our knowledge, this is the first reported case of HH in the newborn with SARS-CoV-2 infection. Hyerperinsulinism is the most common cause of hypoglycemia in infants. These newborns are at risk of developing significant neurologic morbidity, which can be dose dependent. Prompt diagnosis and aggressive management are important to reduce such risk. Perinatal stress is likely the underlying mechanism leading to HH in newborns with SARS-CoV-2 infection. Patient is also SGA. Both perinatal stress and SGA can lead to inappropriately elevated insulin levels and resultant hypoglycemia. HH in both of these conditions is effectively managed by Diazoxide. Our case illustrates that although most newborns do well with SARS-CoV-2 infection, a high index of suspicion for HH should be maintained in such newborns, particularly in those with at least one other risk factor for HH such as SGA. More studies are needed to elucidate underlying pathology and tease out actual incidence of hypoglycemia in neonates with SARS-CoV-2 infection.