Diabetic ketoacidosis precipitated by Coronavirus disease 2019 infection: Case series.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has evolved into a devastating pandemic since December 2019. Saudi Arabia's first case was reported in March 2020. Subsequently, some 220,000 cases and 2000 deaths were recorded through July 2020. COVID-19 infection aggravates glycemic control and provokes acute hyperglycemic crises, according to some reports. We made the same observations in some of our patients diagnosed with COVID-19. However, we are unaware of any reported cases of diabetic ketoacidosis (DKA) among COVID-19 patients in Saudi Arabia. OBJECTIVE: Highlighting the significance of hyperglycemia on COVID-19 patient outcomes. METHODS: Five patients with DKA were admitted and diagnosed with COVID-19 based on real-time reverse transcription-polymerase chain reaction assays. Electronic medical records were reviewed and informed consent was obtained before reporting the index cases. RESULTS: Five patients presenting with DKA complicating a concurrent COVID-19 infection were reported. Three were known to have preexisting diabetes and 2 had newly diagnosed diabetes based on significantly elevated glycated hemoglobin levels at admission. Four recovered and were discharged to their homes and 1 had a complicated course and died. CONCLUSIONS: Our cases demonstrate that COVID-19 infection can trigger DKA. DKA can occur among patients who are known to have diabetes mellitus or appears as a first presentation. Clinicians should be extremely careful in checking for admission hyperglycemia and closely monitor respiratory status during fluid resuscitation of COVID-19-related DKA. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX).

Perspectives on Prediabetes and Aging.

Diabetes prevention programs (DPPs) have been shown to effectively delay, and sometimes prevent, the progression from prediabetes to diabetes; however, labeling someone with prediabetes comes with potential negative psychological, financial, and self-perception consequences. Many older adults with prediabetes nowadays have a relatively "low-risk" form of prediabetes that rarely progresses to diabetes and may regress to normoglycemia. In this article, we review the impact of aging on glucose metabolism and provide a holistic approach to cases of prediabetes in older adults that maximizes the benefit-risk balance of interventions aimed at addressing prediabetes.

Graves' Ophthalmopathy in the Setting of Primary Hypothyroidism.

Graves' ophthalmopathy (GO) is commonly associated with hyperthyroidism secondary to Graves' disease (GD). Although rare, there have been case reports of it occurring in patients who are hypothyroid with underlying Hashimoto's thyroiditis (HT), as well as in euthyroid patients. Below, we describe a case of GO developing in a patient who has hypothyroidism secondary to HT successfully treated with high-dose steroids. We present a case of a 53-year-old female known to have primary hypothyroidism (Hashimoto's thyroiditis) diagnosed at the age of 39 years and has been on levothyroxine since diagnosis. She presented to our endocrine clinic complaining of new-onset diplopia and periorbital swelling for five months. There is no previous hyperthyroid state or radioactive iodine therapy. Examination showed left-sided upper and lower eyelid swelling, limited abduction with diplopia, and mild punctate keratopathy. Laboratory investigation revealed positive thyroid-stimulating immunoglobulin of 500 IU/mL (normal value: <140 IU/mL) with thyroid-stimulating hormone (TSH) and free thyroxine (FT4) in the euthyroid range. She was found to have a small heterogeneous thyroid gland on ultrasound suggestive of atrophic thyroiditis, and magnetic resonance imaging (MRI) of the orbits demonstrated bilateral ocular proptosis with extraocular muscle enlargement. The patient was diagnosed with active moderate-severe isolated GO with a background of HT, clinically and biochemically euthyroid on levothyroxine. She was referred to an ophthalmologist and was started on a course of high-dose oral prednisone tapered over three months, which was followed by oral selenium and botox injections to both medial recti muscles. Graves' ophthalmopathy is an uncommon presentation in hypothyroid and euthyroid patients but should be considered in the differential diagnosis. The incidence varies between studies from 2% to 7.5%. Awareness of this clinical presentation is important, as early detection and treatment can prevent visual complications. To date, there are no clear guidelines on how to treat GO with underlying HT. Treating our patient with high-dose steroids extrapolated from treating GO secondary to GD showed significant improvement in her symptoms.

Thyroid Storm in a Patient With Alemtuzumab-Induced Graves' Disease: A Case Report.

Thyroid storm (TS) is a rare and life-threatening medical emergency, most commonly caused by Graves' disease (GD). GD can be induced by immune reconstitution therapy (IRT) such as alemtuzumab (ALZ), a humanized monoclonal antibody against CD52, which is shown to be effective in the treatment of relapsing-remitting multiple sclerosis (RRMS). Here, we present a rare case of TS developing in a 39-year-old female with ALZ-induced GD, managed with antithyroid medication followed by thyroidectomy. There is some evidence that ALZ-induced GD may behave less aggressively than conventional GD. However, physicians should be aware that severe thyrotoxicosis and thyroid storm can happen, which requires prompt recognition and aggressive therapy.