COVID-19–Related Multisystem Inflammatory Syndrome in Children Presenting With New-Onset Type 1 Diabetes in Severe Ketoacidosis: A Case Series

Abstract

OBJECTIVE To report and describe cases of children presenting with COVID-19–related multisystem inflammatory syndrome in children (MIS-C) with new-onset type 1 diabetes mellitus (T1DM) in severe diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS This prospective observational study was conducted to characterize children with COVID-19–related MIS-C and new onset T1DM who were in DKA. MIS-C was diagnosed if Centers for Disease Control and Prevention and World Health Organization criteria were fulfilled. RESULTS Six cases were identified. The patients were critically ill and in nonfluid responsive shock (combined hypovolemic and cardiogenic or distributive shock). All had cardiac involvement. One patient had a Kawasaki shock-like presentation. All needed aggressive treatment with careful monitoring of fluid balance (because of associated cardiac dysfunction), early institution of vasoactive/inotropic supports, and use of methylprednisolone and intravenous immunoglobulins. The latter are better administered after DKA resolution to avoid undue volume overload and fluid shifts while the patients are in DKA. CONCLUSIONS Awareness of MIS-C coexistence with DKA at T1DM onset is crucial for rapid proper management.

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

“…New-onset diabetes in COVID-19 patients typically has an abrupt onset, severe but transient hyperglycemic episodes, and may include potentially life-threatening diabetic ketoacidosis; in this regard, it resembles T1DM more than T2DM [89]. For example, in a case series of six pediatric patients with the critical multisystem inflammatory syndrome in COVID-19, all developed diabetic ketoacidosis and were diagnosed with T1DM [90].…”

New-Onset Primary Adrenal Insufficiency and Autoimmune Hypothyroidism in a Pediatric Patient Presenting with MIS-C

“…The pathogenetic mechanisms of both autoinflammatory and autoimmune diseases associated with COVID-19 infection are as yet poorly understood but may involve molecular mimicry, bystander activation, and loss of immune tolerance [ 4 ]. Autoimmune endocrine conditions described following SARS-CoV-2 include type 1 diabetes [ 5 ], autoimmune thyroiditis including hypothyroidism, Graves' disease [ 6 ], and one case of autoimmune adrenalitis in an adult [ 7 ]. We report the first case of autoimmune polyglandular syndrome 2 (APS2) characterized by new-onset primary adrenal insufficiency and autoimmune primary hypothyroidism diagnosed in an adolescent, in the context of COVID-19 infection, presenting with severe systemic symptoms suggestive of MIS-C.…”

A cursed goodbye kiss from severe acute respiratory syndrome-coronavirus-2 to its pediatric hosts: multisystem inflammatory syndrome in children

“…Following the disease definition, fever, rash, cardiac, and GIS involvement signs were reported to be the most common clinical findings of MIS-C, in several cohort studies [14,15 & ,47, [55][56][57][58]. We tried to summarize the main characteristics of MIS-C patients in Table 1 There are also other miscellaneous cases whose cardinal signs have been uncommon such as acute pancreatitis, encephalopathy, cerebellitis, diabetic ketoacidosis, hepatitis, acute appendicitis, mesenteric lymphadenopathy, ocular myasthenia, and papilledema [70][71][72][73][74][75][76][77][78]. Despite the common similarities between Kawasaki disease and MIS-C, only one MIS-C case has been reported to have erythema and induration of Bacillus Calmette-Guerin (BCG) scar so far [79].…”

“…There are also other miscellaneous cases whose cardinal signs have been uncommon such as acute pancreatitis, encephalopathy, cerebellitis, diabetic ketoacidosis, hepatitis, acute appendicitis, mesenteric lymphadenopathy, ocular myasthenia, and papilledema [70–78]. Despite the common similarities between Kawasaki disease and MIS-C, only one MIS-C case has been reported to have erythema and induration of Bacillus Calmette–Guerin (BCG) scar so far [79].…”