Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454

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Diabetes & Metabolic Syndrome: Clinical Research & Reviews

journal homepage: www.elsevier.com/locate/dsx

The association between COVID-19 and type 1 diabetes mellitus: A

systematic review
Mahmoud Nassar, MD, MSc, MHA, MPA. a, *, Nso Nso, MD/MPH a,
Bahaaeldin Baraka, MD, MRCP b, Mostafa Alfishawy, MD c, Mahmoud Mohamed, MD d,
Akwe Nyabera, MD a, Issac Sachmechi, MD e
a
Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H&H Queens, NY, USA
b
Oncology Department, Southend University Hospital, Mid and South Essex NHS Foundation Trust, ESSEX, UK
c
Infectious Diseases Consultants and Academic Researchers of Egypt IDCARE, Cairo, Egypt
d
Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, USA
e
Division of Endocrinology, Department of Medicine, Mount Sinai Services, Queens Hospital, Center, NY, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: /Aim: Various reports of the occurrence of type 1 diabetes mellitus (T1DM) in patients with
Received 25 December 2020 COVID-19 have been published, denoting an association between both diseases. Therefore, we conducted
Received in revised form this systematic review to summarize the prevalence of T1DM in COVID-19 patients and to identify the
2 February 2021
clinical presentations and outcomes in this patient population.
Accepted 4 February 2021
Materials and methods: Up to 10/27/2020, Medline, Embase, cochrane and google scholar databases were
searched for original studies investigating the association between COVID-19 and T1DM. A manual
Keywords:
search was conducted to identify missing studies. The quality of included studies was analyzed by the
COVID-19
T1DM
National Institute of Health (NIH) risk of bias tool. Outcomes included length of hospital stay, hospi-
Diabetes mellitus talization, intensive care unit (ICU) admission, diabetic ketoacidosis (DKA), severe hypoglycemia, and
New onset death.
Results: Fifteen studies were included in the qualitative analysis. Included studies reported data of both
adult and pediatric patients. The prevalence of T1DM in COVID-19 patients ranged from 0.15% to 28.98%,
while the rate of COVID-19 in patients with T1DM ranged from 0% to 16.67%. Dry cough, nausea, vom-
iting, fever and elevated blood glucose levels were the most commonly reported presentations. The
investigated outcomes varied widely among studied populations.
Conclusions: The prevalence of T1DM in patients with COVID-19 ranged from 0.15% to 28.98%. The most
common presentation of COVID-19 in patients with T1DM included fever, dry cough, nausea and vom-
iting, elevated blood glucose and diabetic ketoacidosis. The outcomes of COVID-19 in terms of length of
hospital stay, hospitalization, ICU admission, DKA rate, and severe hypoglycemia were reported variably
in included studies. Due to the heterogeneous study populations and the presence of many limitations,
more studies are still warranted to reach a definitive conclusion.
© 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.

1. Introduction

On March 11, 2020, the World Health Organization (WHO)

recognized the emerging COVID-19 (CoronaVirus Disease-2019) as
* Corresponding author. Department of Medicine, IIcahn School of Medicine at pandemic after recording over 118,000 cases globally in 114 coun-
Mount Sinai/ NYC H&H Queens Hospital Center, 82-68 164th Street Jamaica, New
tries [1]. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-
York, 11432, NY, USA.
E-mail addresses: [email protected], [email protected] CoV-2) is the strain of coronavirus that causes COVID-19. The RNA
(M. Nassar), [email protected] (N. Nso), [email protected] (B. Baraka), virus belongs to the previously merging corona family featured
malfi[email protected] (M. Alfishawy), [email protected] with respiratory manifestations with high case fatality [2,3]. Virus
(M. Mohamed), [email protected] (A. Nyabera), [email protected]
acquisition can occur either by contact directly with infected
(I. Sachmechi).

https://doi.org/10.1016/j.dsx.2021.02.009
1871-4021/© 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.
M. Nassar, N. Nso, B. Baraka et al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454

subjects or indirectly with contaminated objects within the envi- characteristics, radiographic findings, and outcomes/complications
ronment while asymptomatic patients can spread the disease [4,5]. (i.e., hospitalization rate, ICU admission rate, length of hospital stay,
Patients with COVID-19 experience a variety of clinical pre- rate of diabetic ketoacidosis (DKA), and death) in patients with both
sentations ranging from no symptoms or mild illness to critical COVID-19 and T1DM.
illness with multi-organ failure even death [6,7]. Mortality rate of We further did a manual search of references in our included
COVID-19 ranges from 0.7% to 10.8% [8]. Survival decreases, and papers to avoid missing relevant studies. We included all original
more complications tend to develop in advanced age populations studies that reported both COVID-19 and T1DM. The title and ab-
and patients with underlying comorbidities [9]. This has raised stract screening were performed by four independent reviewers.
concerns about those suffering chronic conditions like Type 1 Then, three independent reviewers performed a full-text screening
Diabetes Mellitus (T1DM) [10e12]. to ensure the inclusion of relevant papers in our systematic review.
Reports prove no increase in the risk of infection with COVID-19 Any disagreement was resolved by discussion and referring to the
among children with T1DM and adolescents [13]. Besides, no pre- senior author when necessary.
sent evidence is suggesting higher mortality rates in T1DM children
in comparison with their healthy peers. However, poor outcomes 2.2. Data extraction
and more deaths are recorded in diabetic adults after COVID-19
infection [12]. Two authors developed the data extraction sheet using the
We did not find robust information discussing the consequences Microsoft Excel software. Data extraction was performed by three
and the direct correlation between Covid-19 and T1DM [12]. On the independent reviewers using the excel sheet. The fourth indepen-
other hand, reports are showing that COVID-19 indirectly carries dent reviewer performed data checking to ensure the extracted
risks for T1DM patients on many levels; in some countries, it may data accuracy. All the disagreements and discrepancies were
hinder obtaining adequate health services. The interrupted supply resolved by discussion and consultation with the senior author
of drugs, technology, and care for T1DM patients can result in poor when necessary.
glycemic control and, subsequently, more complications [13]. It also
delays the proper response to emergency situations since a sig- 2.3. Quality assessment
nificant reduction is reported in emergency department access
mainly because of fear of infection [14]. Also, the pandemic is Three independent reviewers evaluated the risk of bias in the
accused of aggravating adaptive psychological difficulties among included studies. The National Institute of Health (NIH) risk of bias
T1DM children [15]. Therefore, we conducted this systematic re- assessment tool was used to assess the quality of included studies
view to summarize the prevalence, clinical findings, and outcomes [17]. Three different tools were used: one for cohort and cross-
of COVID-19 in patients with T1DM, based on the findings of sectional studies (14 questions/items), one for case-control
available evidence. studies (12 questions/items), and one for case series (9 questions/
items). Any discrepancy between the reviewers was solved through
2. Materials and Methods discussion.

2.1. Search strategy and study selection 2.4. Statistical analysis

The study process was conducted following the accepted Due to the scarcity of reported outcome data in included studies
methodology recommendations of the PRISMA checklist for sys- with the wide variations in the studied populations, the conduc-
tematic review and meta-analysis, where registration of the pro- tance of a meta-analysis was inapplicable.
tocol is not mandated [16]. A systematic electronic database search
was conducted for relevant studies published from inception and 3. Results
till 10/27/2020 in 4 databases including Embase, Medline, Cochrane
and Google scholar databases using keywords, medical subject 3.1. Search results
(MeSH) terms and publication types based on the PICO framework
(participants, comparison, intervention, and outcomes). The We identified 893 records after excluding 103 duplicates using
following search terms were used according to each database: the Endnote X9 software. Title and abstract screening resulted in 40
(COVID-19 OR SARS-CoV-2 OR nCoV-2) AND (T1DM OR “type 1 DM” records for further full-text screening. Two papers were added after
OR “type 1 diabetes”). The inclusion criteria were as follows (1) all performing manual search trials. Finally, we included fifteen
original studies (i.e., cohort, cross-sectional, and case-control studies in this systematic review after excluding 27 papers from the
studies): that report the incidence of T1DM in COVID-19 patients full-text screening phase (Fig. 1).
or vice versa, (2) commentaries and case series that included more
than 10 patients, and (3) studies that reported the clinical charac- 3.2. Study characteristics and quality of the included studies
teristics and outcomes of patients with both T1DM and COVID-19.
On the other hand, the exclusion criteria included the following: The baseline characteristics of included studies are summarized
(1) non-original reports (i.e., reviews, letters to editors and com- in Table 1. Fifteen studies were finally included: Eight studies are
mentaries that did not include original patients’ data), (2) case retrospective cohort studies, three are cross-sectional studies
reports and case series including less than 10 patients, (3) unavai- [18e24], two are retrospective case-control studies [25,26], one is
lable full-texts, (4) unextractable or irrelevant data (such as the retrospective case-series [27], and one was a commentary with no
psychological impact of COVID-19 pandemic on patients with clear report of a study design, but the study included original data
T1DM without infection), (5) articles that were not published in [28]. The studied populations were patients with COVID-19 alone in
English, (6) duplicated records, (7) animal studies, and (8) over- two studies [22,27], patients with T1DM alone in five studies
lapped data. [14,21,23,24,28], patients with both COVID-19 and T1DM in five
The primary outcome was to determine the number of COVID- studies [18e20,29,30], and patients with either COVID-19 and
19 patients who had either known or newly diagnosed T1DM and T1DM (case group) and patients with T1DM alone or with COVID-
vice versa. The secondary outcomes included the clinical 19-like disease (control group) in two studies [25,26]. The sample
448
M. Nassar, N. Nso, B. Baraka et al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454

Fig. 1. PRISMA flow diagram of the screening process of this systematic review.

size of included studies ranged from 32 participants [18] to 264,390 most common presentation of COVID-19, accounting for 71.40% (5/
participants [21]. The age of included patients was variable, ranging 7) of patients in the study of Al Hayek et al. [18] Dry cough was the
from pediatric age group to adults and elderly patients. Meanwhile, most common presentation (51%; 58/113) in the study of O’Malley
male patients were present in 39.10%e68.0% of studied populations et al. [30] Fever was the most common presentation (89.9%; 62/69)
[24,25]. in the study of Yang et al. [27] Finally, elevated blood glucose level
was the most common presentation both in the case group (COVID-
3.3. Prevalence of COVID-19 in T1DM and vice versa 19 and T1DM; 48.5%) and in the control group (COVID-19-like
disease and T1DM; 51.60%) in the study of Ebekozien et al. [25]
None of the included studies was designed primarily to deter- The radiographic findings of patients with both COVID-19 and
mine the prevalence of COVID-19 in patients with known T1DM or T1DM were not reported in any of the included studies.
to determine the prevalence of new-onset T1DM in patients with
confirmed SARS-CoV-2 infection. However, the rate of SARS-CoV-2 3.5. Clinical outcomes and complications
infection was reported in six studies investigating patients with
T1DM [14,23,24,28,29,44], with a prevalence rate ranging from 0% The outcomes or endpoints, such as death, hospitalization rate,
[28] to as high as 16.67% (5/30 participants) [24]. Meanwhile, in intensive care unit (ICU) admission rate, DKA, and severe hypo-
patients diagnosed with confirmed COVID-19, the rate of T1DM glycemia, were reported in the majority of included studies. The
(regardless of being newly-diagnosed or with known diabetes) rate of ICU admission ranged from 13.3% [25] to 25.90% [28].
ranged from 0.15% (1/658 participants) [22] to 28.98% (20/69 par- Meanwhile, the rate of intubation alone (not as a composite
ticipants) [27]. outcome) was reported in only one study with a rate of 5.3% (6/113
patients) [30]. Meanwhile, the rate of DKA was reported in four
3.4. Clinical presentation of patients with T1DM and COVID-19 studies [24,25,28,30], ranging from 24.0% [30] to 51.7% [28]. Severe
hypoglycemia was reported as an outcome in only two studies
Four studies reported the clinical findings of COVID-19 in pa- [25,30], with a rate of 5.31% and 3.0%, respectively. The rate of
tients with T1DM [18,25,27,30]. Nausea and vomiting were the COVID-19-related death or mortality was 0% [18], 1.50% [19], 3.0%
449
 Table 1

M. Nassar, N. Nso, B. Baraka et al.

Baseline characteristics of included studies of patients with T1DM and COVID-19 (N ¼ 15).

Author/YOP/ Study Design Population Sample Age Sex Outcome (Study group) Outcome (Control group) Prevalence of T1DM Prevalence Quality
Country size (male) of COVID- rating
19 (NIH)

mean SD N (%) N % type N % type N (%) Type N (%)

Barron/ Population-based COVID-19-related death cases 23,698 all age 14,579 364 1.50% COVID-19-related 23,698 NS NR Poor
2020/UK groups (61.5%) death in T1DM (100%)
[31] cases
Vamvini/ Commentary- Case (hospitalized patients with 35 case (51.8%) case (13.4) 17 1 14.28% DKA 2 7.14% DKA NA NA NA Poor
2020/USA Retrospective T1DM and COVID-19) vs. control vs. control vs. control (48.57%)
[32] case-control study (T1DM alone) (52.3) (12.9)
2 28.50% CAD/CVD 8 28.50% CAD/CVD
10.6 Length of hospital 7.3 Length of hospital
(8.2) stay (6.6) stay
2 28.50% composite 4 14.30% composite
outcome (ICU, outcome (ICU,
intubation, or intubation, or
death) death)
Bhatti/2020/ Cross-sectional COVID-19 and DM 103 45 12.5 69 (67%) 103 NS 3 (2.90%) Poor
UAE [33] study (100%)
Al Hayek/ Retrospective Patients with COVID-19 and 32 all age 14 7 21.90% hospitalization 32 Known 32 (100%) Poor
2020/ study T1DM groups (43.80%) (100%) T1DM
Saudi
Arabia
[34]
0 0.00% death
Di Dalmazi/ Retrospective Patients with T1DM 130 all age 71 130 Known 1 (0.77%) Poor
2020/Italy cohort study groups (54.60%) (100%) T1DM
450

[35]
O’Malley/ Multicenter cross- Patients with T1DM and COVID- 113 39.9 16.4 55 58 51.32% hospitalization 111 Known 113 (100%) Poor
2020/USA sectional study 19 (48.67%) (98.33%) T1DM
\[30]

Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454
5 4.00% death 2 Newly
(1.77%) diagnosed
T1DM
27 24.00% DKA
6 5.31% intubation
6 5.31% Severe
hypoglycemia
Li/2020/ Retrospective Hospitalized patients with 658 297 1 NS 658 (100%) Poor
China [22] cohort study COVID-19 (45.14%) (0.15%)
Rabbone/ Cross-sectional Patients with T1DM 160 0-14# 160 NS 8 (5%) Poor
2020/Italy study (100%)
[36]
Pla/2020/ Retrospective Patients with T1DM 50 43.4 15.6 23 (46%) 50 NS 1 (2%) Poor
Spain [37] cohort study (100%)
Yang/2020/ Retrospective case Hospitalized patients with 69 61a 52-67a 34 20 COVID-19- 69 (100%) Poor
China [38] series COVID-19 (49.30%) (28.98%) related
Diabetes
Unsworth/ Commentary- Patients with T1DM 33 1.9e16.8# 22 (68%) 12 36.00% Severe DKA 30 Newly 5 (16.67%) Poor
2020/UK Multicenter (90.10%) diagnosed
[39] regional study T1DM
Cariou/2020/ Multicenter Diabetic patients hospitalized 1317 69.8 13 855 39 (3%) NS 1317 Poor
French observational for COVID-19 (64.90%) (100%)
[40] study
Atlas/2020/ NR Patients with T1DM 58 32 15 25.90% ICU admission 58 NS 0 (0%) Poor
Australia (55.20%) (100%)
[41]
 M. Nassar, N. Nso, B. Baraka et al.
30 51.70% DKA
Holman/ Population-based Patients with T1DM 264,390 all age 149,680 432 0.16% COVID-19 related 264,390 NS NS Poor
2020/UK cohort study group (56.60%) death (100%)
[42]
Ebekozien/ Multicenter case- Case (T1DM and COVID-19) vs. 64 20.9 14.84 25 10 30.30% ICU admission 4 13.30% ICU admission NA NS NA Poor
2020/USA control study control (COVID-19-like and (39.10%)
[43] T1DM)
9 27.20% Hospitalization 2 6.70% Hospitalization
1 3.00% Death 1 3.30% Death
15 45.50% DKA 4 13.30% DKA
1 3.00% Severe 2 6.70% Severe
hypoglycemia hypoglycemia
a
Median and Interquartile range; #: Range; NR: Not Reported; NS: Not Specified; NA: Not Applicable (case-control study); DM: Diabetes Mellitus; T1DM: Type 1 Diabetes Mellitus; ICU: Intensive Care Unit; DKA: Diabetic
Ketoacidosis; NIH: National Institute of Health Quality Assessment Tool.
451

Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454
M. Nassar, N. Nso, B. Baraka et al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454

[25], and 4.0% in studied populations of COVID-19 and T1DM [30]. 4.2. The presentation of COVID-19 in patients with T1DM

Four studies reported the most common presenting symptoms

3.6. Risk of bias of included studies
of COVID-19 in patients with both T1DM and COVID-19. In the study
of Al Hayek et al. [18], nausea and vomiting, as well as DKA, were
All of the fifteen included studies had a high risk of bias (low
the most common presenting symptoms (5/7, 71.40%). In the study
quality) based on the assessment through the NIH tool (Table 1).
of O’Malley et al. [30], dry cough was the most common presen-
tation (58/113, 51.0%) followed by fever or elevated body
4. Discussion temperature-not specified- (56/113, 50.0%). Meanwhile, in the
study of Yang et al. [27], fever was the most common presenting
4.1. The association between T1DM and COVID-19 symptom (62/69, 89.90%) followed by cough (45/69, 65.2%).
Furthermore, Ebekozien et al. [25] compared the presentation be-
Although many studies, including systematic reviews and meta- tween cases (COVID-19 and T1DM) and controls (COVID-19-like
analyses, that investigated the association between COVID-19 and disease and T1DM), and they found that high blood glucose
T1DM have been published, this is the first comprehensive review levels, fever, and dry cough were the most common presenting
to systematically summarize the association between both condi- symptoms in both the case and control groups; however, the pre-
tions, the most common presentation, and the clinical outcomes of sentation of these symptoms was slightly higher in the case group.
patients with COVID-19 and T1DM. In our review, we included a Based on the scarcity of relevant data, no conclusions can be drawn
total of 15 studies (8 retrospective cohort studies, 3 cross-sectional regarding the presentation of COVID-19 in patients with T1DM due
studies, 2 retrospective case-control studies, 1 retrospective case to the variation in the studied population (the incidence of these
series, and 1 study of non-specified design). The prevalence of symptoms differ from hospitalized patients to community-based or
T1DM (known, newly-diagnosed, and non-specified) in patients population-based studies).
with SARS-CoV-2 infection was reported in three studies. In the
study of Li et al. [22], the prevalence of T1DM was 0.15% (1/658), 4.3. The clinical outcomes and complications in patients with T1DM
while it was 3.0% (39/1317) in the study of Cariou et al. [20] Yang and COVID-19
et al. [27] conducted a study among hospitalized patients with
COVID-19, and they found that COVID-related T1DM (fasting Death due to COVID-19 was reported as a single outcome or a
plasma glucose of 7 or more mmol/L 2 months during hospitali- composite outcome in some of the included studies. For instance,
zation without a previous diagnosis of diabetes) occurred in 28.98% Barron et al. [19] reported that 1.50% (364/23,698 patients) of pa-
(20/69) of patients. This difference could be attributed to the dif- tients with T1DM died from COVID-19. Noteworthy, the reported
ferences in studied populations, the timing of conduction of the rate of 1.50% does not reflect those with both T1DM and COVID-19
study (during the early pandemic vs. during the late pandemic). but rather describe the death rate due to COVID-19 among the
Inconsistently, Kumar et al. [45] conducted a systematic review and overall studied population. Meanwhile, Vamvini et al. [26] studies
meta-analysis of case-control studies to investigate the prevalence cases with COVID-19 and T1DM and a control group T1DM patients
of DM in patients with confirmed COVID-19 diagnosis. The authors alone. The authors reported that composite outcome (ICU admis-
included 33 studies in their final meta-analysis, which revealed sion and/or intubation and/or death) was dramatically higher in the
that the pooled prevalence of DM in patients with COVID-19 was case group, with a rate of 28.50% (2/7) compared to the 14.30% (4/
9.8% (95% confidence interval (CI) ¼ 8.7%e10.9%) after adjusting for 28) in the control group. However, there was no statistically sig-
the encountered heterogeneity. This finding is different from ours, nificant difference between both groups, and this could be attrib-
but this could be attributed to the fact that these authors investi- uted to the very small sample size. Noteworthy, Al Hayek et al. [18]
gated the prevalence of DM, overall, and not just T1DM. And, the found no mortality cases in patients with T1DM and COVID-19.
low rate of T1DM among COVID-19 patients in our study could be Inconsistently, the mortality rate was lower in the study of
explained by the fact that T1DM is far less common compared to O’Malley et al. [30], who reported a rate of 4.0% (5/113). On the
type 2 DM (T2DM), which was reported in the majority of analyzed other hand, the rate of COVID-19-related death was very low in the
studies in the review of Kumar et al. [45] Another possible factor is study of Holman et al. [21], who reported a rate of 0.16% (432/
that some of these studies may have been conducted in areas where 264,390). Furthermore, in the study of Ebekozien et al. [25], it was
COVID-19 was highly prevalent, while it was less prevalent in other noted that the mortality rate was slightly lower in the case group
countries. (COVID-19 and T1DM, 3%), compared to the control group (COVID-
Moreover, it is hypothesized that SARS-CoV-2 might itself cause 19-like disease and T1DM, 3.3%). Of note, Yang et al. [27] found that
diabetes. This has been observed in the previous SARS-CoV-1 COVID-19-related T1DM was significantly associated with a higher
infection [46]. Therefore, the association between COVID-19 and mortality rate compared to peers (P ¼ 0.0019). On the other hand,
new-onset diabetes still warrants further investigation in both the study of Cariou et al. [20] reported that the risk of death was
adults and young children. In this context, we also aimed to lower in patients with T1DM (OR ¼ 0.44; 95% CI: 0.11e1.86).
investigate whether COVID-19 increased the incidence of newly- However, this difference did not reach statistical significance. This
diagnosed T1DM; however, relevant data were only reported in wide variation in the rate of COVID-19-related deaths in the studied
two studies. Ebekozien et al. [25] included patients with COVID-19 populations, as well as the differences in the risk of death in T1DM,
and T1DM; among them, 15.6% (5/33) had new-onset diabetes. This may be attributed to many factors. For instance, the clinical het-
rate was higher than the study of O’Malley et al. [30], with a erogeneity in studied populations (hospitalized patients vs.
prevalence rate of 1.77% (2/113). On the other hand, Unsworth et al. community-based cases; adults vs. children; the presence of
[24] reported a prevalence rate of new-onset diabetes of 90.1% (30/ comorbidities vs. absence of comorbidities) could substantially
33) among 33 diabetic patients, of whom only 5 were diagnosed of impact the interpretation of these findings. Also, the burden and/or
COVID-19. This substantial difference could be explained by the the prevalence of COVID-19 in different regions of the world is not
minimal number of included participants in each study, which the same, and the exact reason for this variation is not yet clearly
would result in the over- or under-estimation of the real burden of understood, and this could possibly account for the differences in
COVID-19 among patients with T1DM. our findings.
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M. Nassar, N. Nso, B. Baraka et al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 15 (2021) 447e454

Diabetic ketoacidosis was a prevalent outcome in patients with 6. Conclusions

COVID-19 and T1DM. The rate of DKA was lowest in the study of
Vamvini et al. [26], with a rate of 14.28% (1/7); however, this rate Based on available evidence, the prevalence of T1DM in patients
was higher than that observed in controls (without COVID-19, with COVID-19 ranged from 0.15% to 28.98%. The most common
7.14%; 2/28). Other studies reported higher rates of DKA in pa- presentation of COVID-19 in patients with T1DM included fever,
tients with COVID-19 and T1DM, where O’Malley et al. [30], re- elevated blood glucose, dry cough, nausea and vomiting, and dia-
ported a rate of 24.0% (27/113), Unsworth et al. [24] reported a rate betic ketoacidosis. The outcomes of COVID-19 in terms of length of
of 36.0% (12/33), and Atlas et al. [28] reported a rate of 51.7% (30/ hospital stay, hospitalization, ICU admission, DKA rate, and severe
58). Noteworthy, in the study of Ebekozien et al. [25], it was noted hypoglycemia were reported variably in the included studies. Due
that the rate of DKA in patients with COVID-19 (case group) was to the heterogeneous study populations and the presence of many
three folds that of patients without COVID-19 (control group) limitations, more studies are still warranted to reach a definitive
(45.5% vs. 13.3%), respectively. conclusion.
Length of hospital stay was only reported in one study, where
patients with both COVID-19 and T1DM had higher mean hospital
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