The Perfect Storm: Rapid Progression of Diabetic Ketoacidosis in Pediatric Diabetes in the Setting of COVID-19

Modarelli, Rachel; Balikcioglu, Pinar Gumus; Hendrix, Grace; DeRusso, Michelle; Ozment, Caroline

OBJECTIVE: The coronavirus disease-2019 (COVID-19) pandemic has introduced countless challenges to the medical field. While pediatric patients are reported to have lower rates of COVID-19 mortality, the presence of pre-existing conditions can heighten the severity of their clinical presentation. CASE REPORT: Our patient, a six year old female with known type 1 diabetes, presented with acute onset of abnormal breathing and altered mental status. The day prior, she had one episode of emesis, diarrhea, and abdominal pain, but no fever. She presented to an outside hospital and was reported to have agonal breathing with a GCS of 8 (eyes open to pain, no verbal response to stimuli, and localizes pain). She was promptly intubated and initial labs revealed severe diabetic ketoacidosis (DKA). With a family member with COVID-19, she tested COVID-19 positive. RESULTS: Our patient’s rapid progression and severity of illness requires discussion of how COVID-19 might affect diabetes and indicates opportunities for improving clinical practice in children with preexisting diabetes. We discuss how COVID-19 might change the underlying pathophysiology of DKA and cause metabolic complications. Possible mechanisms include binding to angiotensin-converting enzyme 2 (ACE2) receptors, and enabling a proinflammatory “cytokine storm”. Additionally, ketoacidosis and altered mental status have been present in patients with COVID-19 without diabetes, which might potentiate the symptoms in developing DKA. CONCLUSION: Prompt recognition of DKA is warranted as caregivers may attribute the symptoms to COVID-19 rather than DKA, resulting in increased severity of illness on presentation with acute symptom onset, as described in this report.