New-onset Diabetic Ketoacidosis Research Articles

Unmasking the escalation: a comparative analysis of diabetic ketoacidosis severity before and during the COVID-19 pandemic in a Tunisian pioneer study

ABSTRACT Background The severity of diabetic ketoacidosis (DKA) at diagnosis increased during the global COVID-19 pandemic. This study aimed to analyze the impact of the pandemic on the clinical and biological severity of DKA in patients with new-onset diabetes mellitus (DM) in Tunisia. Research design and methods The study included patients hospitalized for new-onset DKA 2 years prior and 2 years during the COVID-19 pandemic. Data was collected retrospectively, and DKA severity was classified based on biological parameters like potential of hydrogen (pH) and HCO3-. Results The results showed that DKA was more severe during COVID-19, as evidenced by lower potential of hydrogen (pH) (p = 0.006), and serum bicarbonate (HCO3-) levels (p = 0,005). Despite the higher severity of DKA was higher during COVID-19, intensive care unit hospitalizations remained equivalent (p = 0.359). The prevalence of hyponatremia was also higher during COVID-19 (p = 0.024). Conclusion The findings suggest that delayed diagnosis and COVID-19 May contribute to the increased severity of DKA and electrolyte imbalance during the pandemic. Further research is needed to better understand the underlying mechanisms and develop appropriate strategies to address this issue.

Delayed diagnosis of new onset pediatric diabetes leading to diabetic ketoacidosis: a retrospective cohort study.

Patients with a delayed diagnosis of diabetes are more likely to present in diabetic ketoacidosis (DKA). The objective of this study was to assess the prevalence, risk factors, and consequences of missed pediatric diabetes diagnoses in emergency departments (EDs) potentially leading to DKA. Cases of children under 19 years old with a first-time diagnosis of diabetes mellitus presenting to EDs in DKA were drawn from the Healthcare Cost and Utilization Project database. A total of 11,716 cases were included. A delayed diagnosis of diabetes leading to DKA was defined by an ED discharge in the 14days prior to the DKA diagnosis. The delayed diagnosis cases were analyzed using multivariate analysis to identify risk factors associated with delay, with the primary exposure being child opportunity index (COI) and secondary exposure being race/ethnicity. Rates of complications were compared across groups. Delayed diagnosis of new onset diabetes leading to DKA occurred in 2.9 %. Delayed diagnosis was associated with COI, with 4.5 , 3.5, 1.9, and 1.5 % occurring by increasing COI quartile (p<0.001). Delays were also associated with younger age and non-Hispanic Black race. Patients with a delayed diagnosis were more likely to experience complications (4.4 vs. 2.2 %, p=0.01) including mechanical ventilation, as well as more frequent intensive care unit admissions and longer length of stays. Among children with new-onset DKA, 2.9 % had a delayed diagnosis. Delays were associated with complications. Children living in areas with lower child opportunity and non-Hispanic Black children were at higher risk of delays.

Distinct changes to pancreatic volume rather than pancreatic autoantibody positivity: insights into immune checkpoint inhibitors induced diabetes mellitus

BackgroundImmune checkpoint inhibitors (ICI) are promising treatment options for various cancers. However, their use is associated with immune-related adverse events (irAEs), including ICI-induced diabetes mellitus (ICI-DM). This study aimed to investigate the clinical features of ICI-DM, with a particular focus on alterations to pancreatic volume.MethodsWe conducted a retrospective review of 2829 patients who received ICI treatment at the Chang Gung Memorial Hospital, Linkou, between January 2014 and December 2021. New-onset diabetes or diabetic ketoacidosis (DKA) was identified in ten patients receiving ICI therapy. Pancreatic volumes were assessed by manual segmentation of computed tomography (CT) images before and after ICI-DM diagnosis.ResultsAmong these ten patients, nivolumab was the most commonly used ICI (50.0%), followed by pembrolizumab (30.0%) and atezolizumab (20.0%). One patient received combination therapy with nivolumab and ipilimumab. The median age was 63.01 years (range: 40.1 − 87.8). ICI-DM developed after a median of 13.5 cycles (range: 2 − 42) of ICI treatment or 9.85 months (range:1.5 − 21.3) since ICI initiation. The initial presentation was DKA in 60.0% of patients. All patients had low or undetectable C-peptide levels (range: <0.033 − 0.133 nmol/L) and were negative for most type 1 diabetes mellitus (T1DM)-related autoantibodies; only one patient tested positive for glutamic acid decarboxylase antibodies. CT imaging revealed significant pancreatic atrophy, with a median pancreatic volume decrease of 19.92% (P = 0.038) from baseline and sustained significant decline at last follow-up (median − 37.14%, P = 0.012).ConclusionsICI-DM is often accompanied by pancreatic atrophy and approximately two-thirds of patients initially present with DKA. Although the majority of ICI-DM patients lack T1DM-related autoantibodies, identifying diminished pancreatic volumes through CT imaging provides valuable clues into the subclinical aspects of ICI-DM development, aiding in the prevention of diabetic emergencies.Trial registrationNot applicable.

New-onset severe Diabetic Ketoacidosis in a 13-months old Nepali Toddler: a case report

Diabetes mellitus (DM) is a glucose metabolism disorder with diabetic ketoacidosis (DKA) being the most common complication associated with significant morbidity and mortality. Unlike other patients with typical symptoms of abdominal discomfort, pain, nausea and emesis of DKA, our patient presented with atypical symptoms such as cough, runny nose and fast breathing. This symptoms would have initially misled with diagnosis of respiratory tract infection, which would have caused delay in the treatment of DKA. In our patient DKA was treated with intravenous fluid replacement followed by intravenous insulin infusion, along with monitoring of blood glucose and electrolyte levels. We would like to emphasize that DKA can be precipitated by simple upper respiratory tract infection in toddlers with undiagnosed type 1 DM. Hence, random blood sugar measurement and urine for ketone bodies test should be performed if feasible in sick patients presenting with respiratory tract illness-like symptoms.

Comparison of Diabetic Ketoacidosis Characteristics During- and Before the COVID-19 Pandemic.

Despite evidence about the relationship between diabetic ketoacidosis (DKA) and infectious diseases, our knowledge of DKA during the coronavirus disease 2019 (COVID-19) pandemic remains unclear. This study aimed to compare the DKA situation among individuals with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic compared to pre-pandemic. This retrospective-longitudinal study included individuals with T1DM and T2DM hospitalized with newly diagnosed DKA before (March to August 2018 and 2019) and during (March to August 2020 and 2021) the COVID-19 pandemic. Demographics, the frequency of new-onset diabetes mellitus (DM) and new-onset DKA, days of hospitalization, DKA severity, laboratory tests, and mortality were assessed. Of 162 patients with DKA, 139 patients were newly diagnosed. The frequency of individuals with new-onset DM had increased during the pandemic compared to pre-pandemic (P = 0.047). Moreover, new-onset DKA was higher in 2020 and 2021 versus 2019 and 2018 (P = 0.002). Significantly, there were no T2DM patients with DKA in pre-pandemic, but DKA admissions in people with T2DM increased in 2021 (P < 0.001). The severity of new-onset DKA had increased during the pandemic compared to pre-pandemic (P = 0.000). However, there was no significant difference between pre-and the pandemic regarding mortality (P = 0.981). Additionally, hospitalization length (P = 0.043) and mortality (P = 0.038) were higher in patients with T2DM compared to T1DM. During the COVID-19 pandemic, the frequency of DKA and its severity was higher than in pre-pandemic, and COVID-19 can be more life-threatening in patients with T2DM. Therefore, healthcare providers should be alert to DKA, especially in patients with T2DM.

New-onset type 1 diabetes in children and adolescents as postacute sequelae of SARS-CoV-2 infection: A systematic review and meta-analysis of cohort studies.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents may increase risk for a variety of post-acute sequelae including new-onset type 1 diabetes mellitus (T1DM). Therefore, this meta-analysis aims to estimate the risk of developing new-onset type 1 diabetes in children and adolescents as post-acute sequelae of SARS-CoV-2 infection.PubMed/MEDLINE, CENTRAL, and EMBASE were systematically searched up to March 20, 2023. A systematic review and subsequent meta-analyses were performed to calculate the pooled effect size, expressed as risk ratio (RR) with corresponding 95% confidence interval (CI) of each outcome based on a one-stage approach and the random-effects estimate of the pooled effect sizes of each outcome were generated with the use of the DerSimonian-Laird method.Eight reports from seven studies involving 11 220 530 participants (2 140 897 patients with a history of diagnosed SARS-CoV-2 infection and 9 079 633 participants in the respective control groups) were included. The included studies reported data from four U.S. medical claims databases covering more than 503 million patients (IQVIA, HealthVerity, TriNetX, and Cerner Real-World Data), and three national health registries for all children and adolescents in Norway, Scotland, and Denmark. It was shown that the risk of new-onset T1DM following SARS-CoV-2 infection in children and adolescents was 42% (95% CI 13%-77%, p = 0.002) higher compared with non-COVID-19 control groups. The risk of developing new-onset T1DM following SARS-CoV-2 infection was significantly higher (67%, 95% CI 32 %-112%, p = 0.0001) in children and adolescents between 0 and 11 years, but not in those between 12 and 17 years (RR = 1.10, 95% CI 0.54-2.23, p = 0.79). We also found that the higher risk for developing new-onset T1DM following SARS-CoV-2 infection only exists in studies from the United States (RR = 1.70, 95% CI 1.37-2.11, p = 0.00001) but not Europe (RR = 1.02, 95% CI 0.67-1.55, p = 0.93). Furthermore, we found that SARS-CoV-2 infection was associated with an elevation in the risk of diabetic ketoacidosis (DKA) in children and adolescents compared with non-COVID-19 control groups (RR = 2.56, 95% CI 1.07-6.11, p = 0.03).Our findings mainly obtained from USmedical claims databases, suggest that SARS-CoV-2 infection is associated with higher risk of developing new-onset T1DM and diabetic ketoacidosis in children and adolescents. These findings highlight the need for targeted measures to raise public health practitioners and physician awareness to provide intervention strategies to reduce the risk of developing T1DM in children and adolescents who have had COVID-19.

OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS

BackgroundMissed diagnosis can predispose to worse condition-specific outcomes. ObjectiveTo determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. MethodsWe evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. ResultsWe analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4–3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5–3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5–11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8–37.1), or death (aOR 28.4, 95% CI 1.4–207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2–0.9). Other illness complications were not significantly different by missed diagnosis. ConclusionsChildren with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.

Clinical profile and outcome of critically ill COVID-19 patients with diabetic ketoacidosis: A single-centre cross-sectional study in South India.

Clinical profile and outcome of critically ill COVID-19 patients with diabetic ketoacidosis: A single-centre cross-sectional study in South India.

Incidence of new-onset type 1 diabetes during Covid-19 pandemic: A French nationwide population-based study

AimThe association between infection with SARS-CoV-2 and the development of new-onset type 1 diabetes mellitus (T1DM) is unclear. The aim of this study was to examine the impact of the Covid-19 pandemic on the hospitalization rates for new-onset T1DM and diabetic ketoacidosis at diagnosis, in metropolitan France. MethodsThis nationwide retrospective cohort study included hospital data on all patients aged 1 to 35 years old, hospitalized in France due to onset of T1DM, in 2020 and 2021 compared to 2019. ResultsApart from a decrease during the lockdown in 2020, the number of hospitalizations due to new-onset T1DM was not significantly different in 2020 and 2021 than it was in 2019. In the regions most affected by Covid-19 and covering 7,995,449 inhabitants aged from 1 to 35 years old, standardized hospitalization rates were not significantly different in 2020 and in 2021 compared with 2019. The number of hospitalizations for diabetic ketoacidosis at diagnosis was not significantly different after week 14 in 2020 and in 2021 compared with 2019. ConclusionIn this nationwide study, the incidence of hospitalizations for new-onset T1DM and the incidence of diabetic ketoacidosis at diagnosis was not increased during the Covid-19 pandemic in 2020 and 2021. Our results support the fact that infection with SARS-CoV-2 does not promote the development of T1DM.

Statin Therapy is Associated with Higher Risk of Diabetic Complications: A Population-Based Cohort Study

BackgroundData regarding diabetic complications with chronic statin use among Asian population is very limited. Hence, we investigated diabetic progression in diabetic patients receiving statin therapy by evaluating the association with acute and chronic diabetic complications. MethodsThis retrospective population-based cohort study included patients aged 40 years or older who were diagnosed with type-2 diabetes mellitus (T2DM) in Hong Kong between January 1st, 2009 and December 31st, 2009 and followed up till December 31st, 2019. Patients were divided into statin users and non-users, and propensity score matching (PSM) was performed based on demographics, prior comorbidities, and medications. The study outcomes were new-onset Diabetic Ketoacidosis/ Hyperosmolar Hyperglycaemic State (DKA/HHS), new diabetic ophthalmological, neurological, and renal complications. ResultsAfter 1:1 PSM, the study cohort consisted of 3,247 statin users (48.6% male, age 65.03±11.99 years, mean follow-up 5.68±2.39 years) and 3,247 (50.5% male, age 63.20±12.15 years, mean follow-up 5.78±2.34 years) matched statin non-users. Cox proportional hazards model analyses showed that statin therapy was associated with a higher risk of new diabetic renal complications (HR: 1.44, [1.21-1.71], p<0.001), new diabetic ophthalmological complications (HR: 1.44, [1.19-1.73], p<0.001), and new diabetic neurological complications (HR: 1.47, [1.09-1.96], p<0.01), although it was not associated with a higher risk of DKA/HHS (HR: 1.31, [95% CI, 0.89-1.94], p=0.167). The statistical significance of the associations was not maintained under sensitivity analysis which involved excluding patients with previous coronary heart disease. ConclusionAmongst T2DM patients, statin use was associated with higher risk of developing chronic diabetic complications after PSM with multiple adjustments.

Diabetes and SARS-CoV-2-Is There a Mutual Connection?

SARS-CoV-2, a newly emerged virus described for the first time in late 2019, affects multiple organs in humans, including the pancreas. Here, we present the bilateral link between the pathophysiology of diabetes and COVID-19, with diabetes being COVID-19 comorbidity, and a complication of SARS-CoV-2 infection. Analysis of clinical data indicates that patients with chronic conditions like diabetes are at increased risk of severe COVID-19, hospitalization, ICU admission, and death compared to the healthy subjects. Further, we show that SARS-CoV-2 infection might be also associated with the development of new-onset diabetes and diabetic ketoacidosis. We then discuss the options for studying SARS-CoV-2 infection in pancreatic settings, including the use of human pluripotent stem cell-derived pancreatic organoids. Further, we review the presence of SARS-CoV-2 receptors in different pancreatic cell types and the infection efficiency based on pancreatic sections from COVID-19 patients and primary human islet in vitro studies. Finally, we discuss the impact of SARS-CoV-2 infection on human pancreatic cell homeostasis, focusing on β-cells.

New-Onset Diabetic Ketoacidosis Precipitated by COVID-19 in Children :a case report

There is increasing evidence that the 2019 coronavirus disease (COVID-19) is considered as a potential trigger virus for the development of diabetes mellitus in children. This can occur even in patients without factors predisposing to impaired glucose metabolism like obesity . Here, we report a rare case of diabetic ketoacidosis revealing new-onset diabetes and precipitated by COVID-19. The relationship between type 1 diabetes mellitus and COVID-19 is discussed. Results: A 13 years old girl developed symptoms suggestive of diabetic ketoacidosis preceded by polyuria, polydipsia, and lethergy. There is a documented COVID-19 infection in her parents . An asymptomatic infection was detected on the basis of a reverse transcription polymerase chain reaction (RT-PCR) . she responded well to treatment, including rehydration regimens and intravenous insulin. On the 4th day of her hospitalization, she was transferred to several injections of subcutaneous insulin with therapeutic and nutritional education from the parents. Conclusion. COVID-19 can induce acute onset diabetes and diabetic ketoacidosis in children. More research data are needed to improve our knowledge of this constellation and to guide the most appropriate therapies.

IDF21-0273 New-Onset Diabetic Ketoacidosis as a first manifestation of Covid-19 at emergency department

Background: The increased prevalence of Ketoacidosis Diabetes (DKA) nowadays could be partly related to delayed hospital admission or the effect of COVID-19 in exacerbating and/or triggering DKA, possesses a real challenge in managing patients; requiring special considerations and management protocols. Aim: We aimed to evaluate patients admitted to our emergency department with new onset DKA who had a COVID-19 infection. Method: We presented four cases admitted to the hospital with newly diagnosed DKA associated with COVID-19. We also reviewed almost all published cases of DKA that had been precipitated by COVID-19. Results: A total of 4 of the patients with newly diagnosed and SARS-CoV-2 PCR positive. The mean age was 40.5 years old ± 16.5. The average time duration between the onset of symptoms of DKA to admission was 2 days. The most common symptoms were asthenia (50%) and digestive symptoms (25%). All patients had a Glasgow Coma Score below 15 and 3 patients had severe DKA. Concerning the biochemical characteristics, the median pH was 6.97 ± 0.17, HCO3- 5.7 ± 1.4 mmol/l and PCO2 28.6 ±10.5 mmHg. The outcome was favorable in 3 patients. Discussion: The link between COVID-19 and diabetes remains controversial and whether diabetes itself indeed increases the susceptibility of infection or COVID-19 infection alters the subsequent risk of new-onset diabetes remains the main question. Efforts should be done to continuously raise awareness about diabetes as well as the importance of seeking timely medical guidance.

Increase in the Number of Pediatric New-Onset Diabetes and Diabetic Ketoacidosis Cases During the COVID-19 Pandemic

ObjectiveInfection with SARS-CoV-2 induces a proinflammatory state that causes hyperglycemia and may precipitate diabetic ketoacidosis (DKA) in patients with known or new-onset diabetes. We examined the trends in new-onset diabetes and DKA prior to and following the onset of the COVID-19 pandemic. MethodsThis single-center retrospective observational study included pediatric patients (aged 0 to <18 years) hospitalized with new-onset type 1 diabetes or type 2 diabetes (T2D) before (March 1, 2018, to February 29, 2020) and after (March 1, 2020 to December 31, 2020) the pandemic onset. Demographic, anthropometrics, laboratory and clinical data, and outcomes were obtained. ResultsAmong 615 children admitted with new-onset diabetes during the entire study period, 401 were admitted before the pandemic onset, and 214 were admitted after the pandemic onset. Children admitted with new-onset diabetes in the postpandemic period were significantly more likely to present with DKA (odds ratio, 1.76; 95% confidence interval, 1.24-2.52) than in the prepandemic phase. Children with DKA after the pandemic onset had higher lengths of hospitalization and were significantly more likely to experience severe DKA (odds ratio, 2.17; 95% confidence interval, 1.34-3.52). A higher proportion of children with DKA admitted to the pediatric intensive care unit required oxygen support after the pandemic onset than before the pandemic onset (8.85% vs 1.92%). Most cases of T2D with DKA occurred following the onset of the pandemic (62.5%). ConclusionA significant increase in T2D cases occurred following the onset of the COVID-19 pandemic with a greater risk of DKA and severe ketoacidosis. Racial disparity was evident with a higher proportion of Black and American Indian children presenting with ketoacidosis following the pandemic onset.

Characterizing progressive beta-cell recovery after new-onset DKA in COVID-19 provoked A-β+ KPD (ketosis-prone diabetes): A prospective study from Eastern India

BackgroundRecent literature suggests a bi-directional relationship between COVID-19 infection and diabetes mellitus, with an increasing number of previously normoglycemic adults with COVID-19 being admitted with new-onset diabetic ketoacidosis (DKA). However, the possibility of COVID-19 being a potential trigger for A-β + ketosis-prone diabetes (KPD) in these patients needs elucidation. Our study aimed at analyzing such a cohort of patients and determining their natural course of β-cell recovery on serial follow-up. MethodsAfter initial screening, n = 42 previously non-diabetic patients with new-onset DKA and RT-PCR positive COVID-19, were included in our ten-month follow-up study. Of these, n = 22 were negative (suspected A-β + KPD) and n = 20 were positive (Type 1A DM) for autoantibodies (GAD/IA-2/ZnT8). Subsequently, n = 19 suspected KPD and n = 18 Type 1A DM patients were followed-up over ten months with serial assessments of clinical, biochemical and β-cell secretion. Amongst the former, n = 15 (79%) patients achieved insulin independence, while n = 4 (21%) continued to require insulin at ten-months follow-up. ResultsOn comparison, the suspected KPD patients showed significantly greater BMI, age, Hba1c, IL-6 and worse DKA parameters at presentation. Serial C-peptide estimations demonstrated significant β-cell recovery in KPD group, with complete recovery seen in the 15 patients who became insulin independent on follow-up. Younger age, lower BMI, initial severity of DKA and inflammation (IL-6 levels), along-with reduced 25-hydroxy-Vitamin-D levels were associated with poorer recovery of β-cell secretion at ten-month follow-up amongst the KPD patients, ConclusionsThis is the first prospective study to demonstrate progressive recovery of β-cell secretion in new-onset A-β + KPD provoked by COVID-19 infection in Indian adults, with a distinctly different profile from Type 1A DM. Given their significant potential for β-cell recovery, meticulous follow-up involving C-peptide estimations can help guide treatment and avoid injudicious use of insulin.

Factors Associated With Hospitalization in Children and Adolescents With SARS-CoV-2 Infection.

In this retrospective study of 319 children with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we assessed whether age, asthma, obesity, diabetes, and socioeconomic status were associated with hospitalization for coronavirus disease 2019 (COVID-19). Demographic and clinical characteristics were assessed using univariate statistics, excluding incidental or unrelated positives. There was a bimodal distribution of age among hospitalized children. Obesity (P < .001) and a past medical history of diabetes (P = .001) were significantly more prevalent in hospitalized children, including cases of new-onset diabetes and diabetic ketoacidosis. Neither a past medical history of asthma nor lower socioeconomic status was associated with hospitalization. Although limited to a single center, the findings in this study may have important clinical implications. Targeted, proactive health outreach to children with obesity and diabetes, with prioritization of preventative efforts such as vaccination, may be important in preventing worse SARS-CoV-2 infection in this vulnerable group.

One year into the clash of pandemics of diabetes and COVID-19: Lessons learnt and future perspectives.

There is a bidirectional relationship between coronavirus disease 2019 (COVID-19) and diabetes. Furthermore, the COVID-19 pandemic has catalyzed the use of technology in diabetes care. Future research is required to assess the impact of COVID-19 on new-onset diabetes and the influence of diabetes on responses to COVID-19 vaccines.

Complications and Outcomes in Patients With Diabetic Ketoacidosis and COVID19

Introduction: COVID-19 infection caused by the novel coronavirus SARS-CoV-2 has been associated with new-onset diabetes and diabetic ketoacidosis. There are currently limited reports observing the effect of COVID-19 infection on outcomes in patients hospitalized with diabetic ketoacidosis (DKA). Methods: This retrospective study used electronic medical records, between March 1, 2020 to September 14, 2020, and included patients aged ≥ 18 years with DKA. Clinical characteristics, hospital course, and complications (ICD-10 codes) were compared between patients admitted with DKA and confirmed COVID-19 infection (COVID+) to those with DKA without COVID-19 infection (COVID-). The American Diabetes Association criteria was used to define DKA. Results: Among 757 patients with DKA, 80 COVID+ patients with and 677 COVID- patients were included (mean age 49.1 years, female 52.7%, African-American 70.4%). Baseline characteristics were similar between groups. The COVID+ group had a lower admission glucose (mean glucose 413.1 ± 218.7 mg/dL vs 441.1 ± 222.6 mg/dL, p-value 0.05), and higher serum bicarbonate levels (18.2 mmol/L vs 16.6 mmol/L, p-value <0.05) compared to the COVID- group. Compared to the COVID- group, COVID+ required a longer time to achieve blood glucose < 250 mg/dl from admission (8.8 hours vs 7.1 hours, p-value <0.01), and had higher rates of acute respiratory failure (48.8% vs 9.5%, p-value <0.001), mechanical ventilation (32.5% vs 10.9%, p-value <0.001), sepsis (37.5% vs 15.7%, p-value <0.001), acute thrombotic events (11.3% vs 2.7%, p-value <0.05), and pneumonia (70% vs 10.3%, p-value <0.001). COVID+ had higher mortality (16.3% vs 3.1%, p-value < 0.001), ICU length of stay (median 5.5 days or 2–58 days vs median 2 days or 2–123 days, p-value <0.001), and total LOS (median 7.5 or 1–47 days vs median 5 days or 1–98 days, p-value <0.001). Both groups required similar total insulin doses throughout the entire hospitalization (mean 143 +/- (SD) vs 142 +/- SD units, p-value 0.088). Conclusion: Our data shows that COVID-19 infection is associated with increased mortality, worse clinical outcomes, and longer LOS among patients hospitalized with DKA, while presenting with less severe hyperglycemia and acidemia compared to those without COVID-19 infection.

New-Onset Diabetic Ketoacidosis Secondary to Nivolumab Therapy in a Patient with Primary Central Nervous System Lymphoma

Introduction: Inhibitors of programmed cell death receptor (PD-1) and its ligand (PD-L1), such as nivolumab and pembrolizumab, confer anti-autoimmune activities and are therefore approved for anti-cancer therapy. Their mode of action removes autoimmunity checkpoints, thus increasing the risk of immune-related adverse events.&#x0D; Case Presentation: This report describes a clinical case of life-threatening diabetic ketoacidosis (DKA) in a patient after long-term nivolumab administration to treat primary central nervous system lymphoma (PCNSL). The patient presented to the emergency department (ED) with symptoms of fatigue, along with nausea and vomiting for two days; laboratory testing revealed significant hyperglycemia (glucose 673 mg/dL), elevated anion gap (&gt;27), metabolic acidosis, ketonemia, glucosuria and ketonuria, findings of which were consistent with DKA. Given no personal history of diabetes mellitus or other autoimmune conditions and additional tests ruling out alternative causes, the patient was suspected of having newly-onset DKA secondary to nivolumab treatment.&#x0D; Management &amp; Outcome: The patient was treated with fluids, electrolytes replenishments and insulin drip, which closed the anion gap and normalized electrolytes. She was transitioned to subcutaneous insulin. The patient recovered well and was discharged on Metformin and longacting insulin, with close follow-up with endocrinology and oncology.&#x0D; Discussion: Autoimmune endocrinopathies induced by checkpoint inhibitors for cancer treatment have been reported in the past. Newly-onset hyperglycemia and DKA are common autoimmunemediated side effects of checkpoint inhibitor uses in patients without prior history of diabetes mellitus. Clinicians should be aware to prevent this potentially life-threatening condition.

Predictors of new-onset diabetic ketoacidosis in patients with moderate to severe COVID-19 receiving parenteral glucocorticoids: A prospective single-centre study among Indian type 2 diabetes patients

Background and aimCOVID-19 infection predisposes to diabetic ketoacidosis(DKA); whether glucocorticoids enhances this risk is unknown.We aimed to study the occurrence of DKA after initiating glucocorticoids in patients with type 2 diabetes mellitus(T2DM) and moderate-to-severe COVID-19, and identify predictors for it. MethodsPatients with T2DM and moderate or severe COVID-19 infection were prospectively observed for development of new-onset DKA for one week following initiation of parenteral dexamethasone. Clinical and biochemical parameters were compared between those who developed DKA (Group A) and those who didnot (Group B). Logistic regression was done to identify independent risk-factors predicting DKA; ROC-curve analysis to determine cut-offs for the parameters in predicting DKA. ResultsAmongst 302 patients screened, n = 196 were finally included, of whom 13.2% (n = 26,Group A) developed DKA. Patients in Group A were younger, had lower BMI, increased severity of COVID-19 infection, higher HbA1c%, CRP, IL-6, D-dimer and procalcitonin at admission (pall < 0.02). Further, admission BMI (OR: 0.43, CI: 0.27–0.69), HbA1c % (OR: 1.68, CI: 1.16–2.43) and serum IL-6 (OR: 1.02, CI: 1.01–1.03) emerged as independent predictors for DKA. Out of these, IL-6 levels had the highest AUROC (0.93, CI: 0.89–0.98) with a cut-off of 50.95 pg/ml yielding a sensitivity of 88% and specificity of 85.2% in predicting DKA. ConclusionThere is significant incidence of new-onset DKA following parenteral glucocorticoids in T2DM patients with COVID-19, especially in those with BMI <25.56 kg/m2, HbA1c% >8.35% and IL-6 levels >50.95 pg/ml at admission.