A Case of Concomitant COVID-19 Infection-Induced Acute Respiratory Distress Syndrome and Diabetic Ketoacidosis: Another Challenge in Fluid Management

Panjawatanan, Panadeekarn; Jha, Samir; Hughes, Joseph; Riesenfeld, Erik

Coronavirus disease 2019 (COVID-19) has been announced as a pandemic worldwide. The respiratory tract is a target organ system, where infection can result in serious complications, like acute respiratory distress syndrome (ARDS). Management of this condition is more challenging in individuals with diabetes who developed diabetic ketoacidosis. We report a case of a 59-year-old male with type 2 diabetes who presented with productive cough, chills, and shortness of breath for four days. On examination, the patient was hypoxemic with bilateral crackles on lung auscultation. The patient’s biochemistry was significant for glucose 387 mg/dL, pH 7.25, positive urine ketones, and lactic acid dehydrogenase (LDH) 325 U/L. An initial chest x-ray showed bilateral peripheral pulmonary infiltrates. The patient was subsequently intubated on the first day for worsening hypoxia due to severe ARDS. He was concomitantly treated for diabetic ketoacidosis (DKA) and hypotension with fluid resuscitation and intravenous insulin. On the same day, his hypoxia worsened with an increase in pulmonary infiltrates, so we stopped intravenous fluids and initiated norepinephrine for 24 hours. His intravenous insulin was initially started at 12 units/hour with subsequent titration down to an average of 5 units/hour. His mechanical ventilation settings followed ARDS guidelines with tidal volume 6 ml/kg based on ideal body weight. Positive COVID-19 was detected from real-time reverse transcription polymerase chain reaction (RT-PCR). After maintaining a negative fluid balance, we were able to extubate in 72 hours. DKA was resolved in 46 hours. In conclusion, type 2 diabetes is rarely affected by DKA, but can be found in up to 27% of cases. There are reports of ARDS as a serious complication in severe DKA in adults and children, yet no data for concomitant DKA and ARDS has been published. We propose that DKA management in COVID-19 patients with ARDS may be similar to the paradigm utilized for other volume restriction in patients with congestive heart failure and end-stage renal failure.