Euglycemic diabetic ketoacidosis in pregnancy with COVID‐19: A case report and literature review

Diabetic ketoacidosis (DKA) is a life‐threatening complication of diabetes and is considered a medical emergency. Euglycemic DKA (EKDA) is a variant of DKA with a normal or minimally elevated glucose level <200 mg/dl. The condition can be difficult to diagnose due to the relatively normal glucose levels. Pregnancy, infection, and a low‐calorie intake are some of the contributing common etiologies of EDKA. Despite a rapid increase in scientific publications on COVID‐19, there are still knowledge gaps regarding the course of COVID‐19 in some patient subset. This is especially the case for pregnant women. In this case report, we discuss the course of COVID‐19 infection in a pregnant woman with gestational diabetes who developed severe euglycemic diabetic ketoacidosis triggered by various precipitating factors, including starvation, caused by COVID‐19 infection and its gastrointestinal effects.     

Euglisemic diabetic ketoacidotic coma caused by dapagliflozin

Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening acute complication of diabetes mellitus (DM). Sodium-glucose co-transporter-2(SGLT-2) inhibitors are new orally administered antihyperglycemic agents. These agents are related with rarely seen euglycemic diabetic ketoacidosis (eDKA) cases, which are difficult to diagnose in emergency department (ED) because of absence of an evident hyperglycemia and may result with potentially dangerous outcomes if missed. In this study, we present a clinical case of a patient, admitted to ED with altered mental status after SGLT2 inhibitor dapagliflozin administration.     

Sodium–glucose cotransporter‐2 inhibitors induced euglycemic diabetic ketoacidosis: Two case reports and a review of the literature

If not detected early, euglycemic diabetic ketoacidosis can be a serious adverse effect of sodium–glucose cotransporter‐2 (SGLT2) inhibitors. Unfortunately, euglycemic diabetic ketoacidosis is underreported in recent trials and missed because of normal blood sugar levels and nonspecific symptoms on presentation. We present two patients with type 2 diabetes mellitus who developed dapagliflozin‐associated euglycemic diabetic ketoacidosis followed by hyperglycemic ketoacidosis. The second patient had euglycemic ketoacidosis twice despite instructions to stop using the medication dapagliflozin.     

Diabetic ketoacidosis mimicking COVID‐19 in an adolescent

Diabetic ketoacidosis (DKA) may be associated with nonspecific symptoms such as dyspnea, tachycardia, anorexia, and vomiting that are similar to COVID‐19. We describe an adolescent who was referred to the emergency department with the above symptoms and died after being discharged, regardless of the differential diagnosis and laboratory findings.     

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.     

Stent thrombosis during COVID‐19 pandemic: A case series

The coronavirus disease 2019 (COVID‐19) pandemic originated from Wuhan, China, in late 2019. In addition to the respiratory system, COVID‐19 also affects other organ systems. The disease can lead to cardiovascular complications such as myocarditis, acute myocardial infarction, acute heart failure, and venous thromboembolism; patients with COVID‐19 experience more thrombotic events than non‐COVID‐19 patients. A 50‐year‐old male cigarette smoker presented to the emergency department (ED) with typical chest pain. His electrocardiography (ECG) showed an anterior STEMI. He developed multiple episodes of ventricular fibrillation (VF) and received defibrillator shocks. His angiogram showed thrombotic severe in‐stent restenosis (ISR) of the left anterior descending (LAD) artery stents. A 70‐year‐old diabetic hypertensive woman presented to the ED with dyspnea and chest pain. The patient had undergone angioplasty two times beforehand, and a fresh angiogram revealed severe thrombotic ISR of LAD stents and another far midpart lesion after the stents. She underwent successful percutaneous coronary intervention (PCI). A 54‐year‐old man presented to the ED with typical chest pain commencing an hour beforehand. He had undergone angioplasty about 10 years earlier. The patient received the Oxford/AstraZeneca COVID‐19 vaccine 36 h before developing chest pain. The ECG revealed an infero‐posterior STEMI, and the angiogram depicted thrombotic occluded ISR in the RCA. The patient underwent successful PCI. Patients with COVID‐19 or even with COVID‐19 vaccination experience stent thrombosis due to a hypercoagulable state. Hence, we need standard guidelines to prevent stent thrombosis.     

Use of B‐complex vitamins and olfactory training for treating COVID‐19–related anosmia

A 42‐year‐old male patient was diagnosed with coronavirus disease 2019. His symptoms improved 2 weeks after lopinavir therapy (800 mg/day). However, he was subsequently diagnosed with complete anosmia. Magnetic resonance brain imaging showed no abnormalities. We prescribed B‐complex vitamins and olfactory training. Forty days later, he recovered.     

Diabetic ketoacidosis with severe hypokalemia and persistent hypernatremia in an adolescent girl with COVID‐19 infection

We report a case of new‐onset type 1 diabetes in a girl presenting with severe diabetic ketoacidosis, complicated by profound hypokalemia and hypernatremia. We describe the clinical course, management challenges, and the potential role of the concomitant COVID‐19 infection in the complexity of this case.     

Tracheo‐esophageal fistula and pleural empyema in the course of SARS‐CoV‐2 infection—A case report

We report a 49‐year‐old patient with COVID‐19 who developed lung abscess, pleural empyema, and tracheo‐esophageal fistula. He underwent cervicotomy, segmental tracheal resection, esophageal‐tracheal fistula excision, and suturing the esophagus, and a classic thoracotomy was performed. Despite the severe infection, the patient was discharged home after successful surgical treatment.     

The association between serum anion gap and all‐cause mortality of unselected adult patients: A retrospective cohort study of >20,000 patients

BackgroundEven though the serum anion gap (AG) is frequently measured in clinical practice, there is not much research that has examined long‐term mortality in unselected adult patients. Our study''s objective was to investigate how serum anion gap levels could be used to predict death in unselected participants.MethodsThe relationship between baseline serum AG levels and short‐, intermediate‐, and long‐term all‐cause mortality in unselected adult patients is examined using the Cox proportional risk analysis, smoothed curve fitting, subgroup analysis, and Kaplan–Meier survival curves.ResultsAfter screening the database using the appropriate method, a total of 26,270 patients were enrolled in our study for the final data analysis. Our study used smoothed curve fit plots and COX proportional risk regression models incorporating cubic spline functions to evaluate the association between AG levels and all‐cause mortality in a non‐selected population, and the results indicated a non‐linear relationship. In the fully adjusted model, we found that AG levels were positively associated with 30‐day, 90‐day, 365‐day, and 4‐year all‐cause mortality in unselected adult patients with HRs of 1.08 95% CIs (1.06, 1.09); 1.08 95% CIs (1.06, 1.09); 1.08 95% CIs (1.07, 1.08); 1.07 95% CIs (1.06, 1.07).ConclusionSerum anion gap levels were positively correlated with all‐cause mortality in unselected adult patients, with increasing levels of serum anion gap increasing patient mortality.     

Acute worsening of glycemic control in a patient with type 2 diabetes and non‐small cell lung cancer after administration of lorlatinib

A patient with non‐small cell lung cancer (NSCLC) exhibited extreme hyperglycemia after lorlatinib treatment. The present case highlights the importance of glucose monitoring during lorlatinib administration and intensifying hyperglycemia treatment.     

Clinical impact and benefits of a simultaneous cardio‐pulmonary rehabilitation in a COVID‐19‐infected patient following cardiac arrest: A case report

Since the advent of the pandemic, cardio‐pulmonary rehabilitation (CR) has been shown to be an effective treatment. However, there are no studies showing data to substantiate its simultaneous application. A 62‐year‐old man was resuscitated for asystole during the work‐up after presenting with a 2‐day history of difficulty breathing. PCR test was positive for COVID‐19. He was intubated and admitted to a negative pressure zone. Symptoms improved in response to acute treatment. Following extubation, respiratory distress persisted, and CR was implemented. Clinical indicators of cardiopulmonary function improved resulting in a successful return to community participation. The decline in cardiopulmonary function has been on the rise among COVID‐19 survivors. The simultaneous application of CR treatment in our patient resulted in improved clinical indicators of cardiopulmonary function. The patient regained full function for independent community participation.     

Euglycemic Diabetic Ketoacidosis Secondary to Dapagliflozin Use: A Case Report

Background

Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a novel class of oral antihyperglycemic agents. They are associated with rare cases of euglycemic diabetic ketoacidosis (DKA), which presents a diagnostic challenge in the emergency department (ED) and potentially severe consequences if missed.

The first presentation of Wolcott‐Rallison syndrome in a four‐month‐old infant with diabetic ketoacidosis (DKA) precipitating by COVID‐19: A case report

Monogenic diabetes mellitus (eg, Wolcott‐Rallison syndrome) is a rare condition. It associates with neonatal or early‐infancy insulin‐dependent diabetes. We reported DKA in the four‐month infant as the first presentation of monogenic diabetes that has accelerated by COVID‐19 infection. Therefore, considering the concurrency of COVID‐19 and DKA is crucial.     

Prognostic value of glucose‐to‐lymphocyte ratio in critically ill patients with acute respiratory distress syndrome: A retrospective cohort study

BackgroundThere is need to identify biomarkers for prognosis of acute respiratory distress syndrome (ADRS). This may allow early and accurate identification of patients with high‐risk ARDS to guide adjustment of clinical treatment and nursing intervention, which would ultimately improve prognosis of patients with ARDS. Biomarkers based on a combination of fasting glucose and lymphocyte counts to predict prognosis in critically ill patients with ARDS remain undefined. In this study, we investigated the association between glucose‐to‐lymphocyte ratio (GLR) and in‐hospital mortality.MethodsThe study obtained data from Medical Information Mart for Intensive Care‐IV (MIMIC‐IV Version 1.0) database. We defined the GLR as fasting glucose/lymphocyte count and the patient in‐hospital mortality was considered as the outcome. In addition, we employed linear and logistic regression models for analysis.ResultsIn total, 1,085 patients with ARDS were included in this study. The eligible participants included 498 female and 587 males, with a mean age of 64.2 ± 17.5 years. Logistic regression analysis demonstrated that higher GLR was an independent risk factor for all‐cause mortality (OR =1.67, 95% CI: 1.26–2.22) after adjusting for age, sex, anion gap, white blood cell count, congestive heart failure, sequential organ failure assessment (SOFA), SBP, DBP, and respiratory rate in both the dichotomized group and subgroups. We also analyzed the in‐hospital mortality to ROC curves by comparing the value between SOFA + GLR and SOFA. The area under the curve (AUC) was 0.6991 for the SOFA + GLR (95% CI: 0.6634–0.7348), and 0.6613 for the SOFA (95% CI: 0.6238–0.6988).ConclusionOur data showed that the GLR was an independent predictor of in‐hospital mortality for patients with ARDS. The GLR is an integrated, readily available clinical biomarker for mortality in patients with ARDS.     

Anesthetic management in a patient with Arnold‐Chiari malformation type 1,5: A case report

A 42‐year‐old male patient with Arnold‐Chiari malformation type 1,5 (ACM‐1,5) came to implant a hip prosthesis. He underwent a previous general anesthesia, with difficult airway management and complication in awakening. In this second surgery, an extradural approach was preferred to keep intracranial pressure and hemodynamics stable.     

目标降糖策略在难治性糖尿病酮症酸中毒的应用

目的探讨糖尿病酮症酸中毒（DKA）的治疗方法。方法经常规治疗无效的DKA患者36例，采取目标降糖策略，给予强化胰岛素治疗和奥曲肽治疗。结果治愈率83．3％（30／36），病死率16．7％（6／36）。血糖控制与低血压、低氧血症纠正呈明显负相关。血糖控制与高渗血症、酸中毒纠正呈明显正相关。结论目标降糖策略是DKA的有效治疗方法。     

New onset diabetes with ketoacidosis attributed to quetiapine

A 45-year-old man with paranoid schizophrenia with delusions was transferred from a group home for treatment of diabetic ketoacidosis (DKA). Six months before this episode, he had been hospitalized in an inpatient psychiatric institution and treated with valproic acid and quetiapine 400 mg with normal blood sugars recorded. The patient was treated for diabetic ketoacidosis, and all outpatient medications were discontinued. Insulin resistance is commonly cited as the mechanism for hyperglycemia, a theory supported by the efficacy of insulin- sensitizing medications in reported cases. Although antipsychotic- associated DKA is uncommon, hyperglycemia associated with these medications is commonplace. Analysis of case series have not identified risk factors for hyperglycemia or diabetic ketoacidosis within this population. Considering the incidence and unpredictability of hyperglycemia associated with quetiapine and atypical antipsychotics, clinicians should initiate intensive monitoring in patients, including weight, hyperglycemia, and dyslipidemia.     

The anion gap (AG): studies in the nephrotic syndrome and diabetic ketoacidosis (DKA)

Although "unmeasured" anions contribute to metabolic acidosis in a variety of disease states, they are generally not measured directly but estimated from the calculation of "gaps." Among the most commonly used method, the anion gap (AG) is not only a function of "unmeasured" anions, but also it is a function of plasma non-carbonate buffers (albumin and phosphate), the plasma pH, and the method of measurement. To clarify the contribution of non-carbonate buffers to the AG, the Figge-Fencl-Waston model of human plasma was applied to laboratory values obtained from two novel populations, patients with nephrotic syndrome and patients with diabetic ketoacidosis (DKA). The model performed adequately, justifying the common clinical practice of correcting the AG for the net protein charge.     

Urinary liver‐type fatty acid‐binding protein: A hemodynamic index during extracorporeal membrane oxygenation

We discuss a case in which urinary L‐FABP measurements were used to manage a 46‐year‐old male patient receiving V‐A ECMO support. His mean blood pressure was ≥75 mmHg for the first 24 h after the initiation of V‐A ECMO, and he experienced a rapid decrease in urinary L‐FABP levels.