Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Associated With COVID 19

Abstract

Background: Cases of patients with combined DKA and HHS associated to COVID-19 are scarce but showed Hispanics patients tended to be associated with higher mortality. Clinical Case: A 51-year-old Mexican man with past medical history of T2DM presented to our hospital with 1-week history of fever, dyspnea, polydipsia, and nausea. Initial vital signs were notable for fever (axillary temperature 39°C) and low oxygen saturation (90% on room air). His examination was notable for a BMI of 31.2 kg/m2. Blood tests showed hyperglycemia (663 mg/dl, n 70–100 mg/dL), hypernatremia (146 mEq/L, n 135–145 mEq/L), hyperchloremia (113 mEq/L, n 95–110 mEq/L), elevated C-Reactive Protein [CRP] (18.7 mg/dl, n < 0.7 mg/dl), elevated lactate dehydrogenase [LDH] (672 U/L, n 100–170 U/L), high D-dimer (3420 ng/ml, n <400 ng/ml), elevated WBC count (13,200 cell/mm3, n 4600–10200 cells/mm3), high neutrophil count (11300 cells/mm3, n 2000–6900 cells/mm3) and low lymphocyte count (200 cells/mm3, n 600–3400 cells/mm3). Arterial blood gas analysis showed metabolic acidosis (pH 7.2 [n 7.35–7.45], bicarbonate 8mmol/L [22–28 mmol/L], anion gap 23.5 [8–16]) with ketones (100 mg/dl, n <5 mg/dl) in the urine analysis. Calculated serum osmolarity resulted of 328 mOsm/kg (n 278–305 mOsm/kg). Electrocardiogram showed no alterations. Chest X-ray revealed bilateral ground-glass opacities with bilateral infiltrates. Blood and urine cultures were negative. The patient tested positive for SARS-CoV-2. Intravenous fluids, insulin infusion with ceftriaxone i.v. (2 g daily) and clarithromycin p.o. (1 g daily) were initiated but did not result in clinical improvement, continuing with fever, hyperglycemia, metabolic acidosis and worsening of respiratory status. At first day of hospitalization, he presented acute respiratory distress syndrome and was intubated and sedated. He developed multi-organ failure and expired after 3 days of mechanical ventilation. Conclusion: DM is a predisposing factor leading to severe COVID-19 disease. Patient showed similar features reported in cases who died of combined DKA and HHS associated with COVID-19: male, Hispanic, poor blood glucose control, mechanical ventilation, elevated CRP with high LDH and D-dimer. In this patient, obesity was an additional feature that led to severe COVID- 19. Reference: Hoe Chan K, Thimmareddygari D, Ramahi A, Atallah L, Baranetsky NG, Slim J (2020) Clinical characteristics and outcome in patients with combined diabetic ketoacidosis and hyperosmolar hyperglycemic state associated with COVID-19: a retrospective, hospital-based observational case series. Diabetes Res Clin Pract 166:108279