Mihail Zilbermint is used to treating diabetes – he heads a special team that cares for patients with the metabolic disorder at Suburban Hospital in Bethesda, Md. But as the hospital admitted increasing numbers of patients with COVID-19, his caseload ballooned.
Dr. Mihail Zilbermint is an Assistant Professor at the Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine. Safe to say, he’s used to treating patients with diabetes. “Before, we used to manage maybe 18 patients per day,” he said. Now his team cares for as many as 30 daily.
No prior history of diabetes.
Many of his patients who developed high blood sugar while they had COVID-19 returned back to normal by the time they recovered. Others who were not as lucky, went home with a diagnosis of full-blown diabetes. “We’ve definitely seen an uptick in patients who are newly diagnosed,” Zilbermint said.
COVID-19 doesn’t just attack the lungs. It’s been associated with a range of other conditions such as blood clots, neurological disorders, and kidney and heart damage. Now, researchers are saying both Type 1 and Type 2 diabetes may soon be added to the long list of symptoms caused by the coronavirus. But scientists do not know whether COVID-19 might hasten already developing problems or actually cause them – or both.
Past outbreaks of influenza and SARS had similar effects.
As early as January 2020, doctors in Wuhan, China, noticed high blood sugar levels in patients infected with the virus. A year after the pandemic began, the COVID-diabetes link is still unclear. Covid-19 patients with high risk factors, such as obesity or a family history of the disease were more likely to develop diabetes during or after treatment. High blood sugar levels were also common in patient taking dexamethasone, a steroid that is a front-line treatment for COVID-19. What’s disturbing is that patients with no known risk factors or prior health concerns also developed diabetes. In some cases, they develop the condition months after the body has cleared the virus.
John Kunkel, a 47-year-old banking executive in Evening Shade, Ark., was one of the surprise cases. He was hospitalized with COVID-19 in early July. During a follow-up visit with his doctor, he learned he had dangerously high blood sugar levels and was readmitted. Kunkel has since received a diagnosis of Type 2 diabetes. “I had no preexisting health issues,” he said. “I was blown away. Why?”
Kunkel has had five emergency room visits and three hospital stays since getting COVID-19. He recently lost his job because he was unable to return to work, given his continuing health problems. “Will you get your life back?” he asked. “Nobody knows.”
Severe Covid-19 patients and diabetes
As many as 14.4 percent of people hospitalized with severe COVID-19 developed diabetes, according to a global analysis published Nov. 27 in the journal Diabetes, Obesity and Metabolism. The international group of researchers sifted through reports of uncontrolled hyperglycemia, or high blood sugar, in more than 3,700 COVID-19 patients across eight studies. While those diagnoses might be the result of a long-observed response to severe illness, or to treatment with steroids, the authors wrote, a direct effect from COVID-19 “should also be considered.”
Researchers do not understand exactly how COVID-19 might trigger Type 1 or Type 2 diabetes, or whether the cases are temporary or permanent. But they are racing to find answers, including whether the novel coronavirus may have spawned an entirely new type of diabetes that might play out differently from the traditional forms of the disease.
Underlying connection between the two diseases.
Over the summer, Francesco Rubino, a diabetes surgery professor and a group of other diabetes experts launched a global registry of patients with COVID-19-related diabetes. After they spread the word with an editorial in the New England Journal of Medicine, more than 350 institutions from across the world responded, he said.
The database is accumulating patients – over 150 so far – although it will take months for researchers to sift through the data to draw any conclusions. “We really need to dig deeper,” Rubino said. “But it sounds like we do have a real problem with COVID and diabetes.”
Some of the cases reported to his database do not fit the usual profile of Type 1 diabetes, in which the pancreas produces little or no insulin, or Type 2, in which people become insulin resistant, he said. Usually, a patient with one type of diabetes will experience specific complications; for instance, those with Type 1 may burn through their fat stores, or those with Type 2 may experience a syndrome that can involve severe dehydration and coma as the body pumps excess blood sugar into the urine. In some patients with COVID-19, though, complications cross types.
“There’s a good chance that the mechanism of the diabetes isn’t typical,” Rubino said. “There could be a hybrid form. It’s concerning.”
Rubino is especially worried about reports of diabetes diagnoses after mild or asymptomatic coronavirus infections. As the number of novel coronavirus infections continues to rise, he said, “you could see a significant new volume of diabetes diagnoses.”
Previous research of coronavirus and diabetes
After the 2003 SARS pandemic, Chinese researchers tracked 39 patients with no history of diabetes who had developed acute diabetes within days of hospitalization with SARS. For all but six, blood sugar level had fallen by the time they were discharged, and only two still had diabetes after two years. The researchers also found evidence that the SARS virus might attack insulin-producing beta cells in the pancreas.
“If scientists could figure out how or if viral infection can damage beta cells, or what role viruses play in the development of the disease, it would be a real turning point,” said Katie Colbert Coate, a diabetes researcher and research instructor in medicine at Vanderbilt University Medical Center.
Type 2 diagnosis in children
Doctors at Children’s Hospital Los Angeles, also noticed an increase in the number of Type 2 diagnoses in children, as well as a severe complication of diabetes. This prompted Senta Georgia, an investigator at the hospital’s Saban Research Institute to dig deeper.
Such reports also have increased the sense of urgency for researchers like Coate, who dropped other work and began looking for keys to understanding the mechanism of the disease by examining how COVID-19 might damage beta cells or other structures in the pancreas. She and others are asking whether certain COVID symptoms predict whether a patient is vulnerable to diabetes and, most important, whether the disease’s onset is an effect of the immune response or a result of the virus directly attacking insulin-producing cells.
At the present moment, the hunt for the mechanism underlying the diabetes-COVID-19 connection continues. For newly diagnosed patients such as nurse practitioner Tanisha Flowers, the answers can’t come soon enough.
Infected in April while working in a COVID-19 ward in a Richmond, Va., hospital, the 40-year-old was diagnosed with diabetes in October. She now takes daily medications, watches her diet and is all too aware that she may be diabetic for life.
“I’m not myself anymore,” Flowers said. “No one knows what the lasting outcomes are.”