On July 12, 2022, a 58-year-old black female retiree with significant symptoms of numbness and muscle weakness in the hands and legs was brought into the emergency room. One day prior, she had been experiencing stomach pain, vomiting, and increasing exhaustion. Her family members have a long history of type 2 diabetes mellitus, including her grandmother and father. She had never used chemotherapeutic medications, been exposed to pollutants, or struggled with alcoholism. She has a background involving medical and pharmaceutical problems. 17 years prior, she received a type 2 diabetes mellitus diagnosis. Metformin 1.5 g twice a day and glibenclamide 10 mg twice a day were part of her therapy regimen. She had consistently taken her medications until her admission date. She made it a habit of traveling outside of the city to visit her younger sister, who was ill. Her sister gave consent for a COVID-19 test to be positive while she was in the hospital. She might have come into contact with COVID-19 two days before admission. When she was admitted to the emergency room, she described a one-day history of shortness of breath, fever, pain in the hands and legs, headache, tingling in the hands and legs, excessive sensitivity to touch, and dehydration. Three days prior to being hospitalized, she was in good health. At the time of her arrival at the emergency room, she had the following vital signs: a body temperature of 39.1°C, a weight of 70.4 kg, a height of 1.60 m, a body mass index (BMI) of 27.5 kg/m2, a blood pressure of 127/89 mmHg, a respiratory rate of 19 cycles per minute, a peripheral pulse rate of 101 beats per minute, and an oxygen saturation level of 86% on room air.
Her blood chemistry done upon her admission to the intensive care unit showed blood urea nitrogen of 36 mg/dl, fasting blood glucose of 229 mg/dL, 2-hour postprandial blood glucose of 232 mg/dL, serum creatinine of 2.2 mg/dl, serum sodium of 117 mEq/L, serum potassium of 3.7 mEq/L, hemoglobin of 14.8 g/dL, leukocytes of 4,310/µL, platelets of 139,800/µL, neutrophils of 65%, pH arterial blood of 7.06, anion gap level of 19 mEq/L, partial pressure of carbon dioxide of 30 mmHg, serum bicarbonate level of 9.6 mEq/L, serum phosphate level of 2.7 mg/dL, white blood cell count of 18720 cells/mm3, serum chlorine level of 91, an aspartate aminotransferase level of 83 units/L, alanine aminotransferase level of 89 units/L, an erythrocyte sedimentation rate of 12mm/hour, 46% hematocrit, lymphocytes 25%, and urine analysis was positive for urine ketones of 3+.
A chest X-ray showed bilateral diffuse, patchy airspace opacities that could be caused by multifocal pneumonia or viral pneumonia. Wheeze, as well as crepitations in the right infrascapular region and bilateral airspace consolidations, which were more pronounced on the left side and involved nearly all zones, were all audible when the chest was auscultated. Her electrocardiogram (ECG) showed sinus tachycardia at 101 beats per minute and ST depression in the anterior-lateral leads. There were no abnormalities or abscesses found during the magnetic resonance imaging. No evidence of compressed nerves was found during the computed tomography scan.
She had never before established an approved COVID-19 infection. The result of the SARSCoV2 reverse transcription polymerase chain reaction was positive. She spent two days in the emergency room with previously well-controlled type 2 diabetes mellitus, the recently diagnosed COVID-19 infection, and newly developed diabetic neuropathy before being transferred to an intensive care unit.
She started receiving 1000 mL of fluid resuscitation (0.9% normal saline) and drip insulin at the critical care unit. She arrived and started breathing five liters of oxygen. Two hours after each meal, she underwent a fasting and random blood sugar check. A fasting blood glucose level of 100 to 140 mg/dL and a 2-hour postprandial blood glucose level of 140 to 200 mg/L were maintained by adjusting the insulin dose in accordance with her blood sugar levels. Enoxaparin 80 mg subcutaneously was given to her every 12 hours to treat her confirmed COVID-19. On day 10, syringe pump insulin therapy was stopped and subcutaneous insulin injections were resumed as soon as her blood sugar started to normalize. She received neutral protamine Hagedorn (NPH) insulin 54/22 after ten days of insulin drip to help with her poor metabolic control. She took 25 mg of amitriptyline once a day, at night. She received 500 mg of acetaminophen as needed to reduce her fever brought on by COVID-19. NPH was stopped after 15 days, metformin 1.5 mg twice daily was restarted, and glibenclamide 10 mg twice daily was resumed. With the aid of subcutaneous insulin and nutritional management, good glycemic control was maintained.
Patient Perspective
On July 29, 2022, she was finally allowed to leave the hospital after receiving two consecutive negative results from COVID-19 throat swab tests. She was discharged with her current diabetes medications as well as painkillers for her diabetic neuropathy. It was advised that she visit the ambulatory clinic for a monthly checkup.