Severe Diabetic Ketoacidosis in Two Children with New Onset type 1 Diabetes after SARS-CoV-2 Infection

Background: An increase in the incidence and the severity of diabetic ketoacidosis (DKA) in children with new onset type1 diabetes has been reported in the COVID-19 pandemic. Studies have linked this to SARS-CoV-2 although causality could not be established. Methods: We report two children with new onset type 1 diabetes and serum autoantibodies against islet cells and glutamic acid decarboxylase who developed severe DKA following infection with SARS-CoV-2. Both tested positive for COVID -19 PCR from nasopharyngeal swabs and developed symptoms of severe DKA, shock and cerebral oedema. Both children deteriorated rapidly illustrating the combined synergistic effects of the inflammatory pathways of COVID -19 and DKA. Results: Both children needed admission to intensive care. The first child had raised inflammatory and cardiac markers and was suspected to have Paediatric multisystem inflammatory syndrome temporarily associated with COVID-19 (PIMS-TS). The period of type 1 diabetes symptoms was short in the second child, she also presented with clinical and biochemical features of pancreatitis which improved with supportive management. She also presented with biochemical thyrotoxicosis at the time of diagnosis. Conclusion: Our report shows the association between infection with SARS-CoV-2 and rapid decompensation to DKA possibly accelerating the development of new-onset type 1 diabetes in genetically predisposed children. Additionally, the second child had pancreatitis illustrating that SARS-CoV-2 can affect both the endocrine and the exocrine function of the pancreas. Enhanced vigilance and earlier intervention is needed to prevent decompensation to DKA.