To the Editor:
In our interim report describing the first 177 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive symptomatic pediatric patients presenting for care at our institution, 5 patients (3%) had an underlying diagnoses of diabetes. All 5 of these patients were female, ranging from 13 to 20 years of age. Four of the 5 patients had type 2 diabetes and only 1 patient had type 1 diabetes. All of the patients had been diagnosed with diabetes from 1.5 to 9.0 years before their SARS-CoV-2 infection; none of these patients had new-onset diabetes and none presented in diabetic ketoacidosis.
Two of the 5 patients did not require hospitalization and both presented with symptoms referable to respiratory infection, rather than any exacerbation related to their underlying type 2 diabetes. One patient presented primarily with minor upper respiratory symptoms without hypoxia. This patient did not present with hyperglycemia or hypoglycemia, but had a history of poor glycemic control despite metformin therapy with consistently and markedly elevated A1C documented as recently as 3 months before infection with SARS-CoV-2. The second patient, who also had asthma as a comorbidity, presented with fever, cough, and diarrhea, but no hypoxia. This patient had been managed with metformin for several years and had undergone bariatric surgery for morbid obesity 16 months before presenting with SARS-CoV-2 infection, but did not have acute glycemic control issues at the time of SARS-CoV-2 diagnosis.
Of the 3 patients with diabetes who required hospitalization, all had systemic symptoms attributable to both SARS-CoV-2 infection, as well as diabetes. One had longstanding type 1 diabetes and prior central nervous system injury secondary to diabetic ketoacidosis/cerebral edema; this patient presented with fever, chest pain, and increased oxygen requirement from baseline. She had a history of good glycemic control (last A1C 7.4%), but had hyperglycemia, without diabetic ketoacidosis at the time of SARS-CoV2 infection. The second patient presented with shortness of breath and chest pain, but no hypoxia, and had concomitant nausea, vomiting, and hypoglycemia. This patient had been diagnosed 1.5 years earlier at an external facility with type 2 diabetes and treated with short-acting insulin rather than oral therapy. However, upon review at our institution, she was deemed to be more consistent with prediabetes rather than diabetes and she was discharged on oral therapy. The third patient had type 2 diabetes with longstanding poor glycemic control despite insulin therapy. She initially presented with fever, chills, nausea, and headache, without respiratory symptoms or acute change in her glycemic control and was managed as an outpatient. However, after improvement in her symptoms, she was admitted 10 days later (after the date of our interim report) with chest pain and shortness of breath, and determined to have pulmonary embolism, as well as significant hyperglycemia (300-400) without diabetic ketoacidosis, requiring initial intravenous insulin therapy. All 3 of these patients had stabilization of their blood glucose levels relatively quickly after hospitalization.