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Review Article | DOI: https://doi.org/10.31579/2640-1045/102
Co-corresponding Author: Maryam Ghandali, Department of Internal medicine, Iran University of Medical Sciences, Tehran, Iran.
1Department of Internal Medicine, Iran University of Medical Sciences, Tehran, Iran.
2Rasoul Akram Hospital,Iran University of Medical Sciences(IUMS),Tehran, Iran.
3Department of Internal medicine, Iran University of Medical Sciences, Tehran, Iran.
4Department of internal medicine, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
5Shahid Beheshti of Medical sciences, independent researcher, Canada.
6Department of Endocrinology, Tehran University of Medical sciences، Tehran, Iran.
7Rajaie Cardiovascular, Medical and Research center, Iran University of Medical Sciences, Tehran, Iran.
8Rasoul Akram Hospital,Iran University of Medical Sciences(IUMS),Tehran, Iran.
*Corresponding Author: Vida Tajiknia, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
Citation: A Ahmadvand, V Tajiknia, M Ghandali, A Afrasiabi, R Pirdehghan, et al. (2021). Looking into a New Challenge, DKA and Covid-19
A Review on Pediatric DKA Cases During New Coronavirus Pandemic Who is to Blame, the Virus or Health System?. J. Endocrinology and Disorders. 5(7): DOI:10.31579/2640-1045/102
Copyright: © 2021 Vida Tajiknia, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 22 September 2021 | Accepted: 14 October 2021 | Published: 19 October 2021
Keywords: type 1 diabetes; diabetic ketoacidosis covid-19
Since the first month of this new pandemic situation, all around the world healthcare system has been facing different challenges and difficulties; patients with chronic diseases such as cancer or diabetes with impaired immune system were at greater risk of infections and complications. It goes without saying that this issue was extremely important among pediatric clinicians dealing with diabetic pediatrics. Diabetes is the number one chronic illness among pediatric patients and the most dangerous and frightened complication of it is Diabetic Ketoacidosis (DKA).
Studies have shown a strong association between pandemic and increase in new diabetes type 1 cases and its lethal complication called DKA.
Here we are going to take a look at existing data and report about cases with this condition trying to find the missing piece of a big puzzle; what is the role of Covid-19 in causing Diabetes in previously healthy kids and what is the real association between SARS-COV2 virus infection and DKA?
We are going to review different studies, possible mechanism, new t1dm cases and old cases, with or without covid infection, DKA cases and its severity.
Viral infections are fully described as a main factor contributing on the pathophysiology of type 1 diabetes mellitus (T1DM). There is extremely rare data about the impact of COVID-19 T1DM and diabetic ketoacidosis (DKA) on paediatric patients [1].
Recent publications have shown the association between type 1 diabetes mellitus (T1DM) and increased morbidity and mortality rates during coronavirus disease (COVID-19) infection [2].
Diabetic ketoacidosis (DKA) is a life-threatening emergency in children and adolescents with manifestation of type 1 diabetes mellitus (DM1) [3].
The severe acute respiratory distress coronavirus 2 (SARS-CoV-2) has been reported to induce ketoacidosis and diabetic ketoacidosis (DKA) even in nondiabetic patients [4]. DKA is a lethal complication of T1DM. Specially in pandemic which newly diagnosed cases are increasing as much as more DKA cases. So we decided to take a closer look to this matter by reviewing current data.
The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has been reported to induce ketoacidosis and diabetic ketoacidosis (DKA) even in previously healthy patients with no history of diabetes.
The pathophysiological mechanism of the SARS-CoV-2 infection can be discussed as different entities as mentioned here; hyperglycemia, and the exacerbated inflammatory cytokine storm [4].
SARS-CoV-2 causing COVID-19 uses angiotensin-converting enzyme 2 receptors for entry into cells, [5] these receptors are present on the surface of pancreatic islet cells. SARS-CoV has been reported to elevate blood sugar and result in a hyperglycemic state. One of the possible theory is that this virus can damage the pancreatic islet cells [2].
With the covid-19 outbreak an increase in pediatric Type 1 Diabetes Mellitus (T1DM) cases was reported. One of the possible explanations is the presence of autoantibody-induced immune dysregulation which is in fact caused by covid-19 [5].
Looking from a different view, it is crucial to take this in mind the social situation in pandemic and the delay to seek medical care can play a key role in this matter. Delay in diagnosis obviously cause critical complications to arise such as DKA [3]. other study also supported [9]. this hypothesis by reporting a meaningful increase in DKA among T1DM patients specially in countries with highest number of covid-19 cases [4].
In summary the mechanism underlying this phenomenon is for sure multifactorial. The factors related to viral nature and factors associated with healthcare system.
In one study conducted in Israel, it was demonstrated that among known pediatric cases of type 1 diabetes there was a significant increase in DKA during the first 3 months of pandemic. However in this multi centric retrospective study there was no significant difference in the severity of DKA in the setting of pandemic world. Please see the table [11].
In a report of 5 patients with 3 of them previously diagnosed with t1dm all 5 were tested positive for covid-19 and also presented with DKA ( 2 moderate 3 mild) [12].
In a study in Philadelphia children hospital 73 newly diagnosed cases were present only 2 of them were tested positive for Covid-19, the incidence of DKA was higher in the first three months of pandemic comparing to the same period of pre pandemic year but after that three months there was no significant difference, which is really interesting since it can support the hypothesis of delay in diagnosis and healthcare biases but also it can be related to limited data.
In a large Cohort study in Germany with 532 children new case of t1dm it was observed that diabetic ketoacidosis both in severe form and mild to moderate has been significantly higher compared with pre pandemic group, 238 patients developed Dka;but the study wasn’t able to pinpoint an exact causality for its findings and it is assumed to be multifactorial [13].
In another study conducted in Saudi Arabia the results were in alignment of previous studies but one interesting fact was also reported.
They reported a number of 106 pediatric patients with new diagnosis of T1DM which had a higher risk of DKA by 26% comparing to pre pandemic group, the interesting part was they have found that the risk of developing DKA is actually higher in female and older children. They suggest that the underlying reason was in fact the because of lockdown and its consequence of delayed presentation [14].
In a study from Australian tertiary center 7 newly diagnosed t1dm were reported 5 presented with dKA, significntly higher compared to pre pandemic group. This study also considered delay
in seeking medical care as the culprit reason [8].
Another interesting report was from Turkey, as it is mentioned in the table was also reported 78 newly diagnosed t1dm with increased rate of DKA to 91% compared to 58% pre pandemic group but this study also showed autoantibodies association with DKA [15].
In Romania 147 newly diagnosed t1dm were reported and 8 of them were positive for covid-19 but 97 cases developed DKA [16].
In another interesting study in Alberta Canada, there was no significant difference between new cases in pandemic versus post pandemic but the DKA prevalence was significantly higher by 68% compared to 45.6% [17].
In a single center retrospective cohort study in Celeveland,USA of 64 patients 13 were newly diagnosed but both group showed a significant increase in presenting DKA comparing to control group from pre pandemic period [18].
DKA at diagnosis of T1DM is a life-threatening situation that represents the main cause of morbidity and mortality in pediatric patients with T1DM [19]. More children with T1D had severe DKA at diagnosis during the pandemic [20].
As the studies showed it is obvious that there is an increase in DKA and new cases with diagnosis of T1DM. In the table we provided here, it was tried to illustrate some of high impact studies which support the idea of pandemic causes new challenges for endocrinologists as managing new T1DM cases and most feared complication of DKA, worldwide;But the aim of this study was to shed light on the missing part of information, the WHY? We did our best to describe that this is multifactorial such as viral pathophysiology, but the key element here was understanding that our health policy and lockdowns and healthcare system around the world might be a double edge sword; as it was mentioned in most cases the cause was pointed to the delay of patients and clinicians to make the diagnosis.
Overall, our study faced some challenges like limited data, the gap of knowledge of exact pathophysiology mechanism responsible for.
T1DM and DKA are two important diagnoses in this pandemic that is better to be approached carefully by pediatricians and educating the public about not to delay to seek medical help seems to be necessary.
Further studies are needed to provide detailed information
T1DM, DKA
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