Severe metabolic ketoacidosis as a primary manifestation of
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The SARS-CoV-2 pandemic and the associated illness COVID-19 have presented a challenge to clinicians, partially due to the initial unfamiliarity with the natural course of COVID-19 and the lack of knowledge on optimal treatment strategies. Knowledge on SARS-CoV-2 has rapidly accumulated, most of which has focused on the unique effects of the virus on the respiratory tract. Clinical manifestation is now known to vary from asymptomatic to respiratory failure and death.

Despite a rapid increase in scientific publications on COVID-19, there are still knowledge gaps regarding the course of COVID-19 in subgroups of patients. This is especially the case for pregnant women. In this case report, we discuss an atypical course of COVID-19 in a woman with a term pregnancy where the primary manifestation was a severe metabolic acidosis.

The patient presented with dyspnoea, tachypnoea, thoracic pain and a 2-day history of vomiting, initially attributed to COVID-19 pneumonia. Differential diagnosis was expanded when arterial blood gas showed a high anion gap metabolic non-lactate acidosis without hypoxaemia. Most likely, the hypermetabolic state of pregnancy, in combination with maternal starvation and increased metabolic demand due to infection, had resulted in metabolic ketoacidosis.

Despite supportive treatment and rapid induction of labour, maternal deterioration and fetal distress during labour necessitated an emergency caesarean section. The patient delivered a healthy neonate. Postpartum, after initial improvement in metabolic acidosis, viral and bacterial pneumonia with subsequent significant respiratory compromise were successfully managed with oxygen supplementation and corticosteroids. This case illustrates how the metabolic demands of pregnancy can result in an uncommon presentation of COVID-19.