Case Series: Exacerbation of Insulin Resistance With Active COVID 19 Infection
Authors: Li Jefferson , Kirupakaran Johnathan , Cabezas Fausto , Martinez Jose , Dave Paulomi , Williams Belinda , Yau Alice , Kim Eunice , Bahtiyar Gul , Rodriguez Giovanna 
Published: May 2021

Abstract
Background: Severe hyperglycemia due to insulin resistance is associated with increased mortality due to induction of pro-inflammatory cytokines, immunodepression, impairing cellular function and healing. We describe 6 patients admitted with COVID19 pneumonia complicated with DKA requiring high dose insulin infusion.
# 1 19 yo African American (AA) male with history of pre-DM and obesity (BMI 41 kg/m2) presented with polyuria, polydipsia, obtunded and intubated in ER. Labs showed pH 7.35, serum sodium (Na) 138 mmol/L, potassium (K) 6.8 mmol/L, chloride (Cl) 85 mmol/L, bicarbonate (HCO3) 10 mmol/L, glucose 1140 mg/dL, lactate 1.4 mmol/L, anion gap (AG) 43, Beta Hydroxybutyrate (BOH) &gt; 4.50 mmol/L. A1c 13.4%. Placed on insulin drip at 29.5 U/hr or 5.7 U/kg/hr. Discharged on Detemir 60 U TID and Novolog 20 U TID ac.
# 2 55 yo female with T2DM and obesity (BMI 37.42 kg/m2) presented with shortness of breath, intubated for hypoxia in ER. Labs showed pH 7.21, serum Na 138 mmol/L, K 5.6 mmol/L, Cl 101 mmol/L, HCO3 13 mmol/L, glucose 557 mg/dL, lactate 5 mmol/L, AG 24, BOH &gt; 0.27 mmol/L. A1c 7.8%. Placed on insulin drip at 23 U/hr or 5 U/kg/hr. Died from multiorgan failure on day 7.
# 3 75 yo Hispanic female with T2DM, HCV, post liver-kidney transplant on immunosuppressants, HTN presented with weakness. Intubated on day 6 for hypoxemia. Placed on stress dose steroids for transplant failure. BMI 30 kg/m2. Labs on day 6 showed pH 6.98, serum Na 140 mmol/L, K 3.5 mmol/L, Cl 100 mmol/L, HCO3 20 mmol/L, glucose 590 mg/dL, AG 20, BOH 1.40 mmol/L. A1c 6.6% a year ago. Placed on insulin drip at 34 U/hr or 10.9 U/kg/hr. She developed ESRD requiring CRRT dialysis. She was made comfort care. Died on day 7.
# 4 38 yo AA male with obesity (BMI 59.5 kg/m2) presenting with confusion, polyuria, polydipsia. Labs showed pH 7.22. serum Na 133 mmol/L, K 6.8 mmol/L, Cl 81 mmol/L, HCO3 15 mmol/L, glucose 1760 mg/dL, lactate 3.8 mmol/L, AG 37, BOH &gt; 4.50 mmol/L. A1c 12.6%. Placed on insulin drip at 36 U/hr or 6 U/kg/hr. Discharged on Detemir 20 U qhs.
# 5 27 yo AA female with T2DM, HTN and obesity (BMI 51 kg/m2), pituitary adenoma presented with seizures. Labs showed pH 7.15, serum Na 133 mmol/L, K 7.0 mmol/L, Cl 84 mmol/L, HCO3 7 mmol/L, serum glucose 951 mg/dL, lactate 1.6 mmol/L, AG 24, BOH &gt;2.45 mmol/L. A1c &gt;15%. Placed on insulin drip at 24 U/hr or 5 U/kg/hr. Died on day 5 from multiorgan failure.
# 6 74 yo Hispanic female with T2DM, HTN and asthma presented with altered mental status. BMI 28 kg/m2. Labs showed pH 7.25, serum Na 155 mmol/L, K 4.6 mmol/L, Cl 125 mmol/L, HCO3 17 mmol/L, serum glucose 779 mg/dL, lactate 2.6 mmol/L, AG 13, BOH &gt;2.45 mmol/L. A1c &gt; 15%. Placed on insulin drip at 24 U/hr or 3.5 U/kg/hr. Died on day 5.
Conclusion: Patients with DM and obesity admitted with Covid19 infection presented with severe insulin resistance and poor outcomes. Cconsideration should be given to assessing therapeutic interventions to enhance insulin sensitivity and improve outcomes.