Introduction: PIMS-TS [Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2] is a unique clinical complication of COVID -19 infection in paediatric patients. We report a case of a child presenting with PIMS-TS and new onset type 2 diabetes.
Presentation: A previously healthy 15 year old boy of Bengali-Indian origin presented to the hospital with polyuria, polydipsia, dry cough, abdominal pain and 1 episode of haemoptysis. He was febrile and tachycardic. Blood glucose was 41 mmol/l but he was not ketotic or acidotic. Diabetes was diagnosed and he was started on subcutaneous insulin. Diabetes antibodies were negative, c-peptide was raised, he was obese with acanthosis nigricans and a strong family history of type 2 diabetes. A diagnosis of type 2 diabetes was made. He was started on antibiotics and initially temperature settled but tachycardia and tachypnoea persisted, he also became hypotensive with lactic acidosis. Inflammatory and cardiac markers for PIMS-TS came back significantly elevated along with abnormal coagulation studies. His neurological status deteriorated and hypertonic saline was given. CT scan of the brain was normal and his neurological status returned to normal in 12 hours. Echocardiogram showed globally severely impaired biventricular systolic and diastolic function hence inotropic support was started. He tested positive for SARS-CoV2 IgG antibodies.
Management: As he fulfilled the criteria for PIMS-TS, he received treatment with Methylprednisolone as per RECOVERY trial regime with prophylactic dalteparin and low dose aspirin. Due to the increasing level of glucose, he was switched to IV insulin. His diabetes management was quite challenging as he had significant insulin resistance and needed IV insulin doses of up to 2 units/kg/day. Requirements improved once Methylprednisolone was discontinued. 72 hours after treatment with IVIG and methyl prednisolone, his clinical course improved and inflammatory markers gradually normalised. His final insulin dose on discharge was 1.2 units/kg/day. Metformin was not started due to initially deranged liver function tests.
Discussion: This is the first reported case of new onset type 2 diabetes and PIMS-TS. The patient had symptoms of diabetes before presenting to the hospital and would have eventually presented with diabetes, but the hyperinflammatory pathway of PIMS-TS may have accelerated the process. Interestingly, he did not develop diabetes ketoacidosis. Low grade inflammation seen in obesity could have contributed to presentation. Corticosteroids used to treat PIMS TS along with increased hepatic glucose production through increased counter-regulatory stress hormones made management quite challenging.
22 Sep 2021 - 26 Sep 2021