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Pediatric Endocrinology Diabetes and Metabolism
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vol. 27
Case report

Ketoacidosis as a primary manifestation of COVID-19

Majidreza Akbarizadeh
Mahin Naderifar
Parisa Ghanizadegan
Mahshid Akbarizadeh

Department of Pediatrics, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran
Dental School, Zahedan University of Medical Sciences, Zahedan, Iran
Pediatr Endocrinol Diabetes Metab 2021; 27 (2): 146–148
Online publish date: 2021/04/22
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Diabetes is a metabolic disease characterized by hyperglycaemia [1]. Diabetic ketoacidosis is the most important metabolic emergency in children, affecting 20–40% of children with type 1 diabetes upon referral to hospitals. Diabetic ketoacidosis (DKA) is usually uncomplicated if diagnosed early and treated appropriately [2, 3]. Various studies have reported that 16–55.3% of children with diabetes mellitus present with DKA [4–8]. The prevalence of COVID-19 is reported to be much lower in children than in adults. The majority of patients have mild symptoms, while some patients are asymptomatic. There is limited information on clinical manifestations among children. Therefore, reporting specific cases can improve the diagnosis process [9]. The present study presents a report on an 18-month-old COVID-19 child who exhibited DKA symptoms.

Case presentation

The case is an 18-month-old male patient weighing 10 kg, who developed high fever, and frequent low-volume blood- and mucus-free diarrhoea from 3 days before the visit. He did not respond to outpatient treatment. From the night before the visit, he exhibited a reduction in consciousness level, and deep and abdominal breathing. He also has no history of illness or hospitalization. The patient’s parents had no history of diabetes, but the patient’s uncle and aunt had a history of type 2 diabetes.
The patient had tachycardia, and fever upon admission (PR: 170, RR: 36, T: 38.8). Pulmonary auscultation showed bilateral wheezes, crackles, and rales. Sugar level at admission was 420 mg/dl. The patient was treated with an initial diagnosis of DKA. Because it is unusual to observe DKA at this age, the presence of fever was also investigated as the cause of such a condition. Preliminary tests showed leukocytosis, ketoacidosis, and hyperglycaemia (Table 1). Brain CT scan was normal. Due to the COVID-19 pandemic, the patient was suspected of having COVID-19. The patient had a positive nasopharyngeal RT-PCR. Chest CT scan also showed evidence in favour of COVID-19. IgM and IgG antibody responses to COVID-19 were measured by enzyme-linked immunosorbent assay (ELISA), and the results were positive for IgM (3.7) and negative for IgG (0.2). The patient underwent meropenem, vancomycin, azithromycin, vitamin C, dexamethasone (low dose), and pantoprazole treatment during hospitalization in the intensive care unit (PICU) in addition to insulin therapy and DKA treatment. Within 10 days of hospitalization, the patient recovered and was finally discharged in good general condition. COVID-19 seems to have caused such conditions in the patient and was the main cause of such conditions.


Both environmental and genetic factors are involved in the development of type 1 diabetes. Environmental factors such as viral infections can damage the pancreas and cause diabetes (10). Other environmental factors include vitamin D deficiency, prenatal factors, cow’s milk (in children under 2 years of age with a genetic predisposition), and viral infections such as cytomegalovirus (CMV), rubella, coxsackie B, and mumps (lymphocyte infiltration destroys beta cells). In fact, type 1 diabetes is a type of T cell-dependent disease. Genetic factors including DR4 and HLA-DR3 are found in 90% of diabetic children [3, 8]. Clinical symptoms of diabetes include polyuria, polydipsia, polyphagia, and weight loss. If ketoacidosis is present, other symptoms may be added. Other symptoms include lethargy and drowsiness (due to hyperosmolarity and decreased cerebral blood flow), tachypnoea and Kussmaul respiration (due to acidosis), fruity-smelling breath (due to acetone), abdominal pain, vomiting, and abdominal distention (due to dehydration, mesenteric ischaemia). On the other hand, serum TG rises due to insulin deficiency, and pancreatitis develops (hypokalaemia-related ileus also causes abdominal pain). Children with DKA have at least 10% dehydration. These children must have azotaemia and high serum BUN and Cr levels. On the other hand, the serum WBC is high (leukocytosis), and the serum sodium level is variable hyperlipidaemia can lead to false hyponatraemia. If a DKA child has a high fever, he/she may have an infection and should undergo antibiotics treatment. If DKA persist for 36 to 48 hours, there is either incorrect treatment or the patient suffers from sepsis and DKA at the same time [11]. With regard to the young boy and the sudden occurrence of such conditions presented in the present study, the patient’s condition and symptoms seem to be a new manifestation of COVID-19 disease. A case-report study showed that an 8-year-old boy with no previous history of the disease developed diarrhoea and abdominal pain and there was no response to treatment after 3 days of supportive treatment. On the fourth day, he developed respiratory symptoms [12] and was admitted to the emergency department with an initial diagnosis of DKA [12]. General practitioners and paediatricians are advised to pay special attention to the nonspecific symptoms of COVID-19, especially those that are similar to life-threatening syndromes. They also should not easily ignore these symptoms and should follow up patients and their recovery status and, if patients do not recover, consider the risk of COVID-19, given the current COVID-19 pandemic.


1. Akbarizadeh MR, Naderifar M, Goli H. Complications affecting newborns of diabetic mothers. J Diabetes Nurs 2019; 7: 887-899.
2. Vanelli M, Chiarelli F. Treatment of diabetic ketoacidosis in children and adolescents. Acta Biomed 2003; 74: 59-68.
3. Castellanos L, Tuffaha M, Koren D, Levitsky LL. Management of diabetic ketoacidosis in children and adolescents with type 1 diabetes mellitus. Pediatric Drugs 2020; 22: 357-367. doi: 10.1007/s40272-020-00397-0.
4. Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden—a 2-year paediatric population study. Diabet Med 2007; 24: 1080-1085. doi: 10.1111/j.1464-5491.2007.02200.x.
5. Neu A, Willasch A, Ehehalt S, et al. Ketoacidosis at onset of type 1 diabetes mellitus in children–frequency and clinical presentation. Pediatr Diabetes 2003; 4: 77-81. doi: 10.1034/j.1399-5448.2003.00007.x.
6. Habib HS. Frequency and clinical characteristics of ketoacidosis at onset of childhood type 1 diabetes mellitus in Northwest Saudi Arabia. Saudi Med J 2005; 26: 1936-1939.
7. Lo FS, Yang MH, Chang LY, et al. Clinical features of type 1 diabetic children at initial diagnosis. Acta Paediatr Taiwan 2004; 45: 218-223.
8. Zhang X, Liu Z, Xia L, et al. Clinical features of vitamin D deficiency in children: A retrospective analysis. J Steroid Biochem Mol Biol 2020; 196: 105491. doi: 10.1016/j.jsbmb.2019.105491.
9. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics 2020; 145: e20200702. doi: 10.1542/peds.2020-0702.
10. Akbarizadeh MR. Comparison of clinical, laboratory, and radiological characteristics of diabetic and non-diabetic children with pneumonia Admitted to Mofid Hospital of Tehran. J Diabetes Nurs 2018; 6: 365-373.
11. Williams V, Muralidharan J. Diabetic Ketoacidosis in Children. IAP Specialty Series on Pediatric Intensive Care 2019; 288.
12. Cherubini V, Gohil A, Addala A, et al. Unintended Consequences of Coronavirus Disease-2019: Remember General Pediatrics. J Pediatr 2020; 223: 197-198. doi: 10.1016/j.jpeds.2020.05.004.
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