New-onset diabetic ketoacidosis with purpura fulminans in a child with COVID-19-related multisystem inflammatory syndrome

Abstract

Background

Coronavirus disease 2019 (COVID 19) usually causes a mild illness among children. However, in a minority of children, it may be associated with the life-threatening multisystem inflammatory syndrome (MIS-C), or thrombotic microangiopathy, or sequelae like type-1 diabetes mellitus (T1DM). We describe a previously healthy, 12-year-old boy with new-onset T1DM with diabetic ketoacidosis (DKA) in the setting of MIS-C, with a course complicated by thrombotic microangiopathy.

Case presentation

The patient presented with four days history of fever, non-bilious vomiting, polyuria and polydipsia. On evaluation, he was noted to have diabetic ketoacidosis. Although Diabetic ketoacidosis with insulin and intravenous fluids, his hospital course was notable for shock requiring vasopressor, purpura fulminans with eschar formation, neurological manifestations (left hemiparesis due to right middle cerebral artery territory infarct, mononeuritis multiplex) and thrombotic microangiopathy. MIS-C-like illness secondary to COVID-19 was suspected due to diabetic ketoacidosis, thrombotic microangiopathy, elevated inflammatory markers, history of contact with COVID-19-infected individual and detectable COVID-19 IgG antibodies. He improved following management with methylprednisolone, intravenous immunoglobulin, low-molecular-weight heparin and aspirin, and was discharged on hospital day 48.

Conclusion

MIS-C-like illness should be considered in children and adolescents presenting with complex multisystem involvement in this era of COVID 19. Management with immunomodulatory agents can be lifesaving.

Keywords:

• Diabetic ketoacidosis
• purpura fulminans
• thrombotic microangiopathy
• COVID-19
• MIS-C

Ethical approval

Taken

Consent

Written informed consent was taken from the parents of the patient. Besides, the child himself provided assent

Author contributions

Dr Parvathi Parappil – concept, designed, drafted the initial manuscript, reviewed and revised the manuscript

Dr Sushant Ghimire– designed, data collection, drafted the initial manuscript, reviewed and revised the manuscript

Dr Apoorv Saxena and Dr Sweta Mukherjee – designed, data collection, drafted the initial manuscript, reviewed and revised the manuscript

Dr B M John – designed, reviewed and revised the manuscript and final approval

Dr Vishal Sondhi- designed, critically reviewed and revised the manuscript and final approval

Dr Suchi Acharya– concept, designed, reviewed and revised the manuscript and final approval

Dr P Sengupta- designed, reviewed and revised the ormalized

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Disclosure statement

No potential conflict of interest was reported by the author(s).