Severe, New-Onset Diabetes Mellitus Triggered by COVID-19 Infection Followed by Euglycemia Upon Recovery: A Case Report

Background: New-onset diabetes mellitus (DM) and severe metabolic complications in association with COVID-19 has been reported in the literature. Studies indicate a bidirectional relationship between COVID-19 and DM. Not only does severe DM lead to an increased risk for COVID-19 complications, but COVID-19 infection itself may precipitate new-onset DM. Clinical Case: A 45-year-old male with no known past medical history and normal body mass index presented after being found unresponsive at home. One week prior to admission, he tested positive for SARS-CoV-2 virus. On admission, laboratory evaluation showed: serum glucose 1090 mg/dl [70–109 mg/dL], anion gap 31 [<12], serum sodium 159 meq/L [133–145 meq/L], serum bicarbonate 18 meq/L [23–30 meq/L], creatinine 2.9 mg/dL [0.7–1.2 mg/dL], serum osmolality 438 mosm/k [280–295 mosm/k], venous pH 7.29 [7.32–7.42], venous bicarbonate 20 mmol/L [24–28 mmol/L], lactic acid 5.0 mmol/L [0.5–2.2 mmol/L], serum acetone positive 1+, urine ketone 20, hemoglobin 16.1 g/dL [14–18.0 g/dL] and HbA1c 13.5% [4.8–5.9%]. A diagnosis of diabetes with hyperosmolarity was made and he was admitted to the medical intensive care unit for treatment. Rapid resolution of hyperglycemia and hyperosmolarity was achieved with insulin infusion and intravenous fluids. He was transitioned to subcutaneous insulin on hospital day 2 and glycemic control was maintained using a basal/bolus insulin regimen. However, he experienced a prolonged two-month hospitalization due to complications including acute respiratory distress syndrome requiring mechanical ventilation and tracheostomy placement, pleural effusions with need for chest tube placement, and acute renal failure requiring short-term hemodialysis support. He was discharged to a rehabilitation facility on insulin glargine 15 units daily. Two-months after discharge, no weight changes were noted. Insulin was discontinued due to fasting serum glucose around 100 mg/dL and HbA1c 5.9%. Six-weeks later, a random serum glucose was 135 mg/dL and HbA1c 6.6%. He remains off glucose-lowering medications to date. Conclusion: We report an interesting case of new-onset diabetes with hyperosmolarity associated with COVID-19 infection with rapid achievement of euglycemia upon resolution of viral infection. Our case adds to growing evidence demonstrating a possible diabetogenic effect due to COVID-19 infection. There is also a complex interplay between SARS-CoV-2 virus and DM leading to a higher risk for complications. Questions remain regarding the long-term effects of COVID-19 on glucose metabolism. Patients with similar clinical presentations warrant close follow-up since it may be possible to de-escalate or discontinue hypoglycemic agents.