Endocrine Abstracts

Introduction: Hyperglycaemic Hyperosmolar State (HHS) is characterised by Hypovolemia, marked hyperglycaemia, Osmolality of 320 mosmol/kg or more with the absence of acidosis and hyperketonaemia (Ph > 7.3, bicarbonate > 15 mmol/l). This is a presentation usually found in people with poorly controlled Type 2 Diabetes Mellitus (T2DM). During the current pandemic of COVID-19, there have been atypical and unusual presentations of Diabetic Emergencies, in patients with well controlled Diabetes having inter-current COVID-19 infection.

Case details: We report the case of an elderly gentleman, with a history of T2DM which was adequately controlled solely by Dietary measures. He was admitted with symptoms of feeling generally unwell and was found to be biochemically in HHS. On examination, he was found to be severely dehydrated with no obvious focalising signs of any infection. Biochemically, he was hyperglycaemic, Serum Osmolality of 361(Sodium- 165, Urea- 17.9) and Ketones were 0.1.On the Full Blood Count, the only marker of note was Lymphocytopenia. As an inpatient, he had consistent spikes of temperature and new Oxygen requirements, which raised the suspicion of COVOD-19 infection following which he had a SARS-COV2-RNA swab which was positive. Radiological evidence was indeterminate for COVID-19.

Management: In accordance with the HHS guidelines, the patient was initially treated with IV Fluids. Following this, he was transferred to the Diabetic ward, where he was started on Insulin, due to persistently raised Blood Glucose levels, despite the fluids. He required high doses of Insulin to alleviate his Blood Glucose levels and was subsequently established on twice a day Insulin regime. In view of his symptoms and the acuity of deterioration in his Diabetes control, COVID-19 swabs were sent off, which confirmed inter current Coronavirus infection.

Summary: This case focuses on the atypical effects and implications that COVID-19 can have in the context of Diabetics, for even those who are well controlled. Infection of SARS-CoV-2 in those with diabetes possibly triggers higher stress conditions, with greater release of hyperglycaemic hormones namely Cortisol and Glucagon, thus leading to increased blood glucose levels and abnormal glucose variability. Among different cytokines found significantly higher in patients with diabetes compared to those without, Interleukin-6 (IL-6), may play a more deleterious role in Covid-19 infection. Even in patients whose Diabetes is well controlled, COVID-19 infection can possibly precipitate an inflammatory response and Cytokine storm, thus resulting in a Diabetic emergency to be the presenting feature.