New-Onset Diabetes with Ketoacidosis Precipitated by COVID-19 in Children: A Report of Two Cases

Covid 19 and diabetes in children: advances and strategies

BACKGROUND

Throughout the COVID-19 pandemic, there has been a notable increase in the incidence of new-onset diabetes and diabetic ketoacidosis (DKA). Simultaneously, children diagnosed with type 1 diabetes (T1D) have encountered difficulties in maintaining optimal blood glucose levels. The mechanisms underpinning these correlations still remain a puzzle. We reviewed the studies that examined changes in incidence during the pandemic. These studies utilized various metrics for comparison, which encompassed the timing of data collection, diagnostic criteria, as well as the numbers and incidence rates of diabetes and DKA. We found the incidence of diabetes and DKA was higher during the pandemic. As to mechanisms, the invivo and invitro study revealed the factors such as direct viral damage, metabolic dysfunction, and immune responses all attribute to the process of T1D after suffering from COVID-19. Furthermore, we provide some useful strategies to prevent and treat children suffering from diabetes and COVID-19.

CONCLUSIONS

Strong correlations have been observed between new-onset diabetes and COVID-19. Insights gleaned from clinical descriptions and basic research can offer valuable experience and recommendations for the treatment and prevention of diabetes during future pandemics.

Exploring the Implications of New-Onset Diabetes in COVID-19: A Narrative Review

Post-viral new-onset diabetes has been an important feature of the COVID-19 pandemic. It is not always clear if new-onset diabetes is the unmasking of a previously undiagnosed condition, the acceleration of prediabetes, or new-onset diabetes that would not have otherwise occurred. Even asymptomatic cases of COVID-19 have been associated with new-onset diabetes. Diabetes that emerges during acute COVID-19 infection tends to have an atypical presentation, characterized by hyperglycemia and potentially life-threatening diabetic ketoacidosis. It is not always clear if new-onset diabetes is type 1 or type 2 diabetes mellitus. Many cases of COVID-associated diabetes appear to be type 1 diabetes, which is actually an autoimmune disorder. The clinical course varies temporally and with respect to outcomes; in some cases, diabetes resolves completely or improves incrementally after recovery from COVID-19. Disruptions in macrophagy caused by COVID-19 infection along with an exaggerated inflammatory response that can occur in COVID-19 also play a role. Those who survive COVID-19 remain at a 40% elevated risk for diabetes in the first year, even if their case of COVID-19 was not particularly severe. A subsequent post-pandemic wave of new diabetes patients may be expected.

Factors Associated With Diabetic Ketoacidosis at Onset of Type 1 Diabetes Among Pediatric Patients: A Systematic Review

IMPORTANCE

Presenting with diabetic ketoacidosis (DKA) at onset of type 1 diabetes (T1D) remains a risk. Following a 2011 systematic review, considerable additional articles have been published, and the review required updating.

OBJECTIVE

To evaluate factors associated with DKA at the onset of T1D among pediatric patients.

EVIDENCE REVIEW

In this systematic review, PubMed, Embase, Scopus, CINAHL, Web of Science, and article reference lists were searched using the population, intervention, comparison, outcome search strategy for primary research studies on DKA and T1D onset among individuals younger than 18 years that were published from January 2011 to November 2021. These studies were combined with a 2011 systematic review on the same topic. Data were pooled using a random-effects model.

FINDINGS

A total of 2565 articles were identified; 149 were included, along with 46 from the previous review (total 195 articles). Thirty-eight factors were identified and examined for their association with DKA at T1D onset. Factors associated with increased risk of DKA were younger age at T1D onset (<2 years vs ≥2 years; odds ratio [OR], 3.51; 95% CI, 2.85-4.32; P < .001), belonging to an ethnic minority population (OR, 0.40; 95% CI, 0.21-0.74; P = .004), and family history of T1D (OR, 0.46; 95% CI, 0.37-0.57; P < .001), consistent with the 2011 systematic review. Some factors that were not associated with DKA in the 2011 systematic review were associated with DKA in the present review (eg, delayed diagnosis: OR, 2.27; 95% CI, 1.72-3.01; P < .001). Additional factors associated with risk of DKA among patients with new-onset T1D included participation in screening programs (OR, 0.35; 95% CI, 0.21-0.59; P < .001) and presentation during the COVID-19 pandemic (OR, 2.32; 95% CI, 1.76-3.06; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, age younger than 2 years at T1D onset, belonging to an ethnic minority population, delayed diagnosis or misdiagnosis, and presenting during the COVID-19 pandemic were associated with increased risk of DKA. Factors associated with decreased risk of DKA included greater knowledge of key signs or symptoms of DKA, such as a family history of T1D or participation in screening programs. Future work should focus on identifying and implementing strategies related to these factors to reduce risk of DKA among new patients with T1D.

Pathogenesis of Type 1 Diabetes: Established Facts and New Insights

Type 1 diabetes (T1D) is an autoimmune disease characterized by the T-cell-mediated destruction of insulin-producing β-cells in pancreatic islets. It generally occurs in genetically susceptible individuals, and genetics plays a major role in the development of islet autoimmunity. Furthermore, these processes are heterogeneous among individuals; hence, different endotypes have been proposed. In this review, we highlight the interplay between genetic predisposition and other non-genetic factors, such as viral infections, diet, and gut biome, which all potentially contribute to the aetiology of T1D. We also discuss a possible active role for β-cells in initiating the pathological processes. Another component in T1D predisposition is epigenetic influences, which represent a link between genetic susceptibility and environmental factors and may account for some of the disease heterogeneity. Accordingly, a shift towards personalized therapies may improve the treatment results and, therefore, result in better outcomes for individuals in the long-run. There is also a clear need for a better understanding of the preclinical phases of T1D and finding new predictive biomarkers for earlier diagnosis and therapy, with the final goal of reverting or even preventing the development of the disease.

COVID-19 in two children with new-onset diabetes: case reports

Delayed diagnosis, low socioeconomic status and infection have been associated with diabetic ketoacidosis (DKA) at type 1 diabetes mellitus presentation. A teenager from a low socioeconomic status family, with longstanding weight loss, polyphagia, polyuria, vomiting and abdominal pain, attended the emergency department, also complaining of anosmia and odynophagia. He was diagnosed with COVID-19 and new-onset DKA. The second child had 2 weeks of diabetes symptoms and was admitted with new-onset mild DKA. SARS-CoV-2 RT-PCR test was positive, although asymptomatic. Persistent hyperglycaemia with high insulin requirements was a common feature to both patients. Both cases support that SARS-CoV-2 may have an association with rapidly increasing insulin daily needs. In case one, not only fear of COVID-19 delayed hospital attendance but also the setting of a low socioeconomic status family appears to have enhanced the risk for late diagnosis and challenging disease management.

Diabetic ketoacidosis and COVID-19: what have we learned so far?

In December 2019, a pandemic emerged due to a new coronavirus that imposed various uncertainties and discoveries. It has been reported that diabetes is a risk factor for worst outcomes of COVID-19 and also that SARS-CoV-2 infection was correlated with the occurrence of diabetic ketoacidosis (DKA) in patients. The aim of this work is to discuss this correlation emphasizing the main case reports from 2020 while exploring the management of DKA during the course of COVID-19. Web of Science, PubMed, and Scopus databases were searched using two sets of Medical Subject Heading (MeSH) search terms or Title/Abstract words: Coronavirus Infections (Coronavirus Infections, Middle East Respiratory Syndrome, COVID-19) and Diabetic Ketoacidosis (Diabetic Ketoacidosis, Diabetic Acidosis, Diabetic Ketosis). There is a clear correlation between COVID-19 and DKA. The SARS-Cov-2 infection may precipitate both a hyperglycemic state and ketoacidosis occurrence in patients with diabetes and nondiabetic patients, which may lead to fatal outcomes. DKA in patients with COVID-19 may increase risk and worse outcomes. Hence, the SARS-Cov-2 infection presents a new perspective toward the management of glycemia and acidosis in patients with diabetes and nondiabetic patients, highlighting the need for rapid interventions to minimize the complications from COVID-19 while reducing its spreading.