Discussion
Ketones are organized in the liver from free fatty acids. ketosis is a
results of reduction in ketone consumption which can be clinically
evident by elevated blood concentrations of ketone bodies (β- and
hydroxybutyrate, acetone acetoacetate). Covid-19 might accelerate fat
breakdown and induce ketosis, with further extension of ketoacidosis
(1).
Euglycemic Dka is a rare and acute life-threatening metabolic emergency
that the normal blood glucose may delay diagnosis and treatment. This
problem is likely due to poor oral intake, treatment with insulin prior
to arrival in the hospital, in pregnant women and with SGLT2 inhibitors
consumption (5).
Dka must be distinguished from other causes of high anion gap metabolic
acidosis including lactic acidosis (which can be associated with
metformin consumption), aspirin or acetaminophen toxicity, methanol or
ethylene glycol poisoning and chronic kidney disease. Although none of
these disorders cause ketoacidosis, several types of acidosis may
coexist, such as lactic acidosis and ketoacidosis (6, 7).
In this report, we introduced a patient who has been infected with
Covid-19 virus in the context of a mild GDM and normal blood sugar with
moderate pulmonary involvement and unexpectedly severe ketoacidosis.
Euglycemic Dka is a rare extrapulmonary manifestation of Covid-19 that
has been reported in both diabetic and non-diabetic patients, as well as
in pregnant and non-pregnant women.
Our patient presented with shortness of breath, fatigue and productive
coughs with intensification from two days ago. At the onset, the
complaints were particularly ascribed to respiratory effects of
Covid-19. Differential diagnosis was expanded when the blood gas
analysis showed a high anion gap metabolic acidosis that was not due
lactate or toxic agents. Urinalysis showed ketone bodies and lower limit
normal blood glucose concentrations at admission. The remaining
diagnosis was euglycemic Dka based on the high metabolic demand in
pregnancy.
Due to the lack of proteinuria, high blood pressure, hemolysis and
increased liver enzymes, preeclampsia also ruled out in this patient.
There are several facts about the physiopathology of ketoacidosis during
infection with Covid-19. Like any other disease, these patients may not
receive a proper intake due to gastrointestinal complaints which can
lead to starvation or fasting Dka (8).
On the other hand, ketogenesis increases in pregnancy and the prevalence
of ketoacidosis is higher in pregnant women than in non-pregnant women:
8.9% vs. 3.1%, respectively, due to the increase in the level of
hormones secreted by the placenta such as placental lactogen and
prolactin, which cause insulin resistance by the antagonistic effects of
insulin, and by stimulating lipolysis, increase the production of free
fatty acids as a substrate for the production of body ketones (9).
Ketoacidosis also occurs in pregnant women with diabetes in the presence
of lower blood sugar, because pregnancy is associated with increased
utilization by creating a hypermetabolic condition and reducing glucose
production in the body (10).
Covid-19 virus has the ability to bind to the ACE2 receptor in the lungs
and pancreas, and by inactivating it, it disrupts insulin secretion and
hyperglycemia. Also, by increasing excessive fluid absorption through
the RAAS system it can cause causes an irreversible state which can lead
to underlying diseases occurrence (11).
Our patient, as in other cases reported from the third trimester of
pregnancy has this complication, and is mild to moderate in terms of the
severity of lung involvement, the rate of arterial blood oxygenation and
biochemical factors associated with the severity of Covid-19 infection,
as other cases reported from mild to medium. It seems that the metabolic
acidosis of these patients is not consistent with the severity of
Covid-19 (2, 12), and the association between Covid-19 infection and
pregnancy is sufficient to cause severe metabolic acidosis.
With regard to the severity of pulmonary involvement with Covid-19 in
this patient, it may be possible to suggest the patient’s blood type,
which was O positive, as a protective factor (13). The patient was
diagnosed with papillary thyroid carcinoma in the first trimester of
pregnancy. Regarding the association between the patient with Covid-19
and ptc, although factors such as inflammation, immunity, obesity, and
oxidative stress are involved, it is not yet clear whether Covid-19
infection could increase or decrease the risk of ptc (14).
Regarding the prognosis of Covid-19 infection in ptc patients, studies
so far have shown that in addition to age and underlying disease
effecting on the hospitalization process of ptc patients with Covid-19,
the treatments and severity of Covid 19 disease in PTC patients were not
correlated. Overall, the rate of hospitalization and mortality in ptc
patients are lower compared to other cancers at the time of Covid-19
infection (15).