Abstract

Case Report

Clinical profile, etiology, outcome and new-onset diabetes: A SARI case series

Siddharth Agarwal*, Sapna Agarwal, Raj Kumar Verma and Shreyash Dayal

Published: 28 June, 2022 | Volume 7 - Issue 1 | Pages: 005-015

Introduction: The world is currently facing the SARS-CoV-2 pandemic with evolving 2nd wave. The COVID-19 patients present most commonly with Severe Acute Respiratory Illness (SARI) in an emergency room with acute onset fever, cough, and breathlessness. However, not all SARI cases as per definition are due to COVID-19 infection, which is well proven in this case series of 113 cases of SARI. This is just the opposite of the other SARI series done in the pre-COVID-19 era. Also, no previous SARI case series data has shown significant association with Diabetes Mellitus, including new-onset diabetes thus figuring out the major Pathophysiological association of COVID-19 with glucose metabolism and has a bearing on the pathogenesis, treatment, and outcome of COVID-19 infection and perpetuity of pandemic of this magnitude. Here we raise concern for the first time about the growing association of an infectious pandemic with the lifestyle disorders which are non-communicable diseases but carry with them the potential of fertile soil for rapidly spreading epidemics.
Aim and objective: To find out the etiology, clinical profile, treatment outcome, and mortality rate in different sub-groups of SARI cases in a tertiary care hospital and the incidence of new-onset Diabetes Mellitus in them and to investigate theoretically the hypothesis that maintaining normal glucose metabolism could prevent progression of a mild Flu-like illness (FLI) to a severe form of Severe Acute Respiratory Illness (SARI) and consequent complications such as Cytokine Storm Syndrome and Multi-Organ failure.
Design: Retrospective, single-center case series of 113 SARI patients at a tertiary care hospital in Agra India between 1 March- 30 October 2020.
Main outcome: The demographics, clinical, pathological, imaging, and treatment outcome data were collected. The SARI cases analyzed were defined as “Severe acute respiratory infections (SARIs) an acute respiratory illness of recent onset (within seven days) manifested by fever (≥38°C), cough and shortness of breath or difficulty in breathing requiring hospitalization and were sub-classified according to the primary etiology producing SARI in them. The findings were compiled and compared. 
Conclusion: Of the 113 patients of SARI – 32.7 %were associated with Diabetes, with 9.74% new-onset Diabetes and 26 % previously known Diabetes. This was mainly due to SARS-CoV-2 (24 Diabetics out of 52 COVID-19 cases- 46.1 %).
The Average hospitalization stay of SARI cases was 10 days with a maximum in SARS-CoV-2 and a minimum stay of 5.22 days in Bacterial Pneumonia and 5.66 days in Koch’s Lungs.
The death rate was maximum (4 out of 26) 15.3%. Hospitalized TB/Koch’s Lung patients who presented as SARI and 3.8% in Bacterial Pneumonia, 2.43% in SARS-CoV-2, and <1% in Sepsis.
Those SARI cases who were euglycemic at the time of initial presentation recovered early and carried a good prognosis with less mortality as compared to those who were hyperglycemic on presentation. Also, those FLI cases who maintained euglycemia or did not have any other risk factor which predisposes them to stress (Diabetes, Prolonged fasting, Obesity, major organ disorder, Psychological disorder, and Cancer) did not progress to SARI as the endogenous steroid secretion and sympathetic activation did not occur, the intracellular pH levels remained in the alkaline range.
10.18% of cases developed new-onset diabetes (a total of 11 cases) out of which 10 were in COVID-19. Thus 19.2% incidence of new-onset diabetes in SARS-CoV-2 and a prevalence of 26.9% in SARS-CoV-2, making total diabetes 46.1% in SARS-CoV-2, and out of all SARI cases, 26 % of patients developed pulmonary fibrosis with consequent long-term complications. In COVID-19 patients, it was seen only in diabetics SARS CoV-2 male patients, thus no death in non-diabetic females in COVID-19 in this case series.

Read Full Article HTML DOI: 10.29328/journal.jcicm.1001041 Cite this Article Read Full Article PDF

References

  1. Hatem A, Mohamed S, Abu Elhassan UE, Ismael EAM, Rizk MS, El-Kholy A, El-Harras M. Clinical characteristics and outcomes of patients with severe acute respiratory infections (SARI): results from the Egyptian surveillance study 2010-2014. Multidiscip Respir Med. 2019 Apr 1;14:11. doi: 10.1186/s40248-019-0174-7. PMID: 30976418; PMCID: PMC6442424.
  2. World Health Organization. Regional Office for Europe. Overview of sentinel systems for hospitalized severe acute respiratory infections (SARI) represented in the weekly Euro Flu surveillance bulletin 2013.
  3. World Health Organization. Regional Office for Europe. Overview of sentinel systems for hospitalized severe acute respiratory infections (SARI) represented in the weekly Euro Flu surveillance bulletin.
  4. Walaza S, Tempia S, Dreyer A, Dawood H, Variava E, Martinson NA, Moyes J, Cohen AL, Wolter N, von Mollendorf C, von Gottberg A, Haffejee S, Treurnicht F, Hellferscee O, Ismail N, Cohen C. The Burden and Clinical Presentation of Pulmonary Tuberculosis in Adults With Severe Respiratory Illness in a High Human Immunodeficiency Virus Prevalence Setting, 2012-2014. Open Forum Infect Dis. 2017 Aug 7;4(3):ofx116. doi: 10.1093/ofid/ofx116. PMID: 28852676; PMCID: PMC5570023.
  5. WHO.
  6. RubinoF. New-Onset Diabetes in Covid-19. Correspondence August 2020. N England Journal Med. 2020; 383:789-790.
  7. Chee YJ, Ng SJH, Yeoh E. Diabetic ketoacidosis precipitated by Covid-19 in a patient with newly diagnosed diabetes mellitus. Diabetes Res Clin Pract. 2020 Jun;164:108166. doi: 10.1016/j.diabres.2020.108166. Epub 2020 Apr 24. PMID: 32339533; PMCID: PMC7194589.
  8. Li J, Wang X, Chen J, Zuo X, Zhang H, Deng A. COVID-19 infection may cause ketosis and ketoacidosis. Diabetes Obes Metab. 2020 Oct;22(10):1935-1941. doi: 10.1111/dom.14057. Epub 2020 May 18. PMID: 32314455; PMCID: PMC7264681.
  9. Ren H, Yang Y, Wang F, Yan Y, Shi X, Dong K, Yu X, Zhang S. Association of the insulin resistance marker TyG index with the severity and mortality of COVID-19. Cardiovasc Diabetol. 2020 May 11;19(1):58. doi: 10.1186/s12933-020-01035-2. PMID: 32393351; PMCID: PMC7213552.
  10. Mallapaty S. Meet the scientists investigating the origins of the COVID pandemic. Nature. 2020 Dec;588(7837):208. doi: 10.1038/d41586-020-03402-1. PMID: 33262500.
  11. United Nations, Statistics Division 761. doi:10.1164/rccm.200912-1918OC. World Health Organization. WHO surveillance case definitions for ILI and SARI. 2014 https://www. who.int/influenza/ surveillance monitoring/ili_ sari_ surveillance_case_definition/en/.
  12. World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected Interim guidance 13 March 2020 WHO Paper.
  13. Gupta N, Praharaj I, Bhatnagar T, Vivian Thangaraj JW, Giri S, Chauhan H, Kulkarni S, Murhekar M, Singh S, Gangakhedkar RR, Bhargava B; ICMR COVID Team. Severe acute respiratory illness surveillance for coronavirus disease 2019, India, 2020. Indian J Med Res. 2020 Feb & Mar;151(2 & 3):236-240. doi: 10.4103/ijmr.IJMR_1035_20. PMID: 32362647; PMCID: PMC7357403.
  14. Hatem A, Mohamed S, Abu Elhassan UE, Ismael EAM, Rizk MS, El-Kholy A, El-Harras M. Clinical characteristics and outcomes of patients with severe acute respiratory infections (SARI): results from the Egyptian surveillance study 2010-2014. Multidiscip Respir Med. 2019 Apr 1;14:11. doi: 10.1186/s40248-019-0174-7. PMID: 30976418; PMCID: PMC6442424.
  15. https://criticalcareblogspot.com/2020/12/10/hyperlactatemia-in-critical-illness-time-for-reappraisal/
  16. Revelly JP, Tappy L, Martinez A, Bollmann M, Cayeux MC, Berger MM, Chioléro RL. Lactate and glucose metabolism in severe sepsis and cardiogenic shock. Crit Care Med. 2005 Oct;33(10):2235-40. doi: 10.1097/01.ccm.0000181525.99295.8f. PMID: 16215376.
  17. Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J; LACTATE study group. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010 Sep 15;182(6):752-61. doi: 10.1164/rccm.200912-1918OC. Epub 2010 May 12. PMID: 20463176.
  18. Al-Toum R, Bdour S, Ayyash H. Adenovirus Infections in Jordanian Hospitalized Paediatric Patients: Prevalence and Clinical Features. J Med J. 2009;43(3):171–17
  19. Pelligrino D. Journal of Cerebral Blood Flow and Metabolism 1:85-96 © 1981 Raven Press, New York Regulation of Extra- and Intracellular pH in the Brain in Severe Hypoglycemia.
  20. Boyle Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database Critical Care. 2018; 22: 268.
  21. Yu S. (2013) Role of Diabetes in the Development of Acute Respiratory Distress Syndrome.
    Crit Care Med. 2013 Dec; 41(12): 2720–2732.

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