Approaching High-Metabolic Risk Youth During a Pandemic: Severe Presentations of New Onset Type 2 Diabetes

Background: Delays in timely medical care due to the restrictions imposed by the COVID-19 pandemic have worsened patient outcomes with different disease conditions. Youth with obesity, insulin resistance, and dysglycemia are increasingly presenting with HHS and/or DKA, leading to increased morbidity and mortality. Case Descriptions:Case 1: A 17-year-old Hispanic female with history of obesity, insulin resistance, and hyperglycemia reported polyuria, polydipsia, and polyphagia for 2 months. The day of admission, EMS was called because patient was found unresponsive at home and required advanced CPR. At arrival to the ED, the patient was awake and responsive. She had acanthosis nigricans and abdominal striae. Initial labs showed elevated plasma glucose (1,256 mg/dL), sodium (153 mmol/L), bicarbonate (9 mmol/L), anion gap (35 mmol/L), phosphorus (7.5 mg/dL; N=3-4.8), lactate (4 mmol/L; N=0.5-2), BHB (11.4 mmol/L; N=0-0.3), venous pH (7.09), BUN (24 mg/dL), creatinine (1.63 mg/dL), and HbA1c (14.3%). She was admitted for DKA, hyperosmolarity, AKI, and metabolic encephalopathy. After IVF resuscitation, insulin drip at 0.05 U/kg/h was started. She recovered from DKA, AKI and hyperosmolarity after 5 days. T1D antibody tests were negative. C-peptide was low (0.7 ng/mL; N=0.8-3.5), and TSH was low (0.38 uIU/mL) with normal free T4 (0.88 mg/dL). Case 2: A 13-year-old Hispanic female with history of asthma, morbid obesity, premature adrenarche, and prediabetes started presenting polydipsia and polyuria 2 months before admission. One day before admission, she presented drowsiness, abdominal pain, and polyuria. Initial labs at the ED included glucose (792 mg/dL), bicarbonate (10.4 mmol/L), anion gap (28 mmol/L), venous CO(2) (10.4 mmol/L; N=21-31), BHB (>22.5 mmol/L), sodium (153 mmol/L), BUN (29 mg/dL), and creatinine (1.37 mg/dL), consistent with DKA, hyperosmolarity, and AKI. Physical exam showed severe obesity, acanthosis nigricans, and hypertension. IV fluids and insulin drip at 0.075 U/kg/h were started. DKA and AKI resolved after 4 days. Labs showed negative T1D antibodies, normal C-peptide (1.2 ng/mL), HgA1C (>14%), microalbuminuria (16.22 mg/dL; N<2 mg/dL), elevated total cholesterol (230 mg/dL) and triglycerides (550 mg/dL). Both youth were negative for SARS-CoV2 and had been engaging in unhealthy lifestyle choices, such as sedentarism and excessive sugary drink intake, exacerbated by COVID-19-related lockdowns and school closures. There were delays in seeking medical care associated to fear of COVID-19. Conclusion: In the current context of a pandemic, it would be helpful to plan close evaluation and timely therapeutic interventions for youth with well-known high-metabolic risks to prevent hospitalizations, severe presentations of T2D and associated morbidity and/or mortality.