Thyroid Crisis Associated with Diabetic Coma

Troen, Philip; Taymor, Robert C.; Goldberg, Bernard I.

doi:10.1056/nejm195103152441103

Cited by 17 publications

(8 citation statements)

References 19 publications

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“…Upon admission to the hospital, she was diagnosed as having DKA and was treated accordingly. Although it has been reported that detection of thyroid storm tends to be delayed in patients with DKA because of suppression of fever [4,7,8], relatively low thyroid hormone levels [9], in the present case, none of these findings was obtained. In this case, the diagnosis of thyroid storm was probably delayed because the symptoms of DKA resembled those of thyroid storm and because no symptoms of Graves' disease were observed before the onset of thyroid storm.…”

Section: Discussioncontrasting

confidence: 67%

Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: A case report

et al. 2011

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BackgroundThyroid storm is a condition in which multiple organ dysfunction results from failure of the compensatory mechanisms of the body owing to excessive thyroid hormone activity induced by some factors in patients with thyrotoxicosis. While diabetic ketoacidosis (DKA) is an important trigger for thyroid storm, simultaneous development of DKA and thyroid storm is rare.Case presentationA 59-year-old woman with no history of either diabetes mellitus or thyroid disease presented to our hospital because of developing nausea, vomiting and diarrhea for 2 days. Physical examination showed mild disturbance of consciousness, fever, and tachycardia. There were no other signs of thyrotoxicosis. Laboratory studies revealed elevation of random blood glucose and glycosylated hemoglobin, strongly positive of urine acetone, and metabolic acidosis. Since DKA was diagnosed, we initiated the patient on treatment with administration of insulin and adequate fluid replacement. Although the hyperglycemia and acidosis were immediately relieved, the disturbance of consciousness and tachycardia remained persistent. Levels of FT3 and FT4 were extremely high and TSH was below the detectable limit. TRAb was positive. The thyroid storm score of Burch & Wartofsky was 75/140, and the thyroid storm diagnostic criteria of the Japan Thyroid Association were satisfied. Oral administration of thiamazole, potassium iodide and propranolol resulted in immediate relief of the tachycardia.DiscussionWe encountered a case of thyroid storm associated with Graves' disease covered by DKA. Thyroid storm and DKA are both potentially fatal, and the prognosis varies depending on whether or not these conditions are detected and treated sufficiently early. The thyroid storm diagnostic criteria prepared in 2008 by the Japan Thyroid Association are very simple as compared to the Burch & Wartofsky scoring system for thyroid storm. The Japanese criteria may be useful in the diagnosis of this condition since they enable clinicians to identify a broad range of cases with thyroid storm. When dealing with cases of DKA or thyroid storm, it seems essential to bear in mind the possibility of the coexistence of these two diseases.

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Section: Discussioncontrasting

confidence: 67%

Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: A case report

et al. 2011

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“…Sixty-five cases of thyrotoxicosis with coma were reported in English-language articles over 84 years between 1935 and 2019. Thirty-six cases were individually reported within small case series [3, 8–16], and 29 were reported as individual case reports [17–45]. The case series (1935 to 2011; median year, 1969) were published earlier than the individual cases (1951 to 2018; median year, 2000).…”

Section: Resultsmentioning

confidence: 99%

“…Table 4 shows the data for the 44 cases reporting details on the relationship between time of coma onset relative to days to awakening or death. Coma was present in 13 patients (30%) at hospital presentation [15, 17–19, 24, 27, 28, 35, 40, 42, 44, 45], in 17 (39%) within the first 2 days of hospitalization [8, 11, 14, 21–23, 25, 26, 29, 30, 33, 37, 41, 43], and in 14 (32%) from day 3 or later of hospitalization. For those presenting with coma, three were found unconscious [40, 42, 45] and one had a witnessed collapse [19].…”

Section: Resultsmentioning

confidence: 99%

Coma in Thyroid Storm: Review of Aggregated English-Language Case Reports

Burmeister

2019

Journal of the Endocrine Society

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Context Coma is a serious manifestation of thyroid storm (TS) about which little is known. Objective To describe the features, duration, treatment response, and prognosis of coma in the setting of TS. Design Aggregate analysis of individual English-language case reports of coma in the setting of TS from 1935 to January 2019. Setting Hospitals. Patients Sixty-five cases were identified, 29 from case reports and 36 from case series. Interventions Antithyroid drugs, corticosteroids, beta-blockers, iodine, intubation, plasmapheresis, antibiotics, thyroidectomy, radioiodine, dialysis, and l -carnitine. Main Outcome Measures Awakening and death rates overall and in relation to administered treatments, day of coma presentation, and time from coma onset; symptoms associated with coma; TS and coma scales; thyroid and cerebrospinal laboratory tests; electroencephalogram; brain imaging; and autopsy results. Results Mortality was 38% in the setting of TS-related coma, 11% during the years 1978 to 2019 compared with 70% for 1935 to 1977. Both awakening and death commonly occurred within the first 2 days of coma onset. Reduction in total and free T4 values, and possibly also total T3 value, correlated with awakening from coma. Lower death rates were associated with use of antithyroid drugs, corticosteroids, beta-blockers, and intubation. Plasmapheresis was associated with awakening in 67% of cases but not with lower death rates. Conclusions Prognosis of coma associated with TS remains poor. Current guidelines for the early use of plasmapheresis in unresolving TS are advocated and should be considered urgently at the point of confusion or delirium in an effort to abort coma.

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“…In the absence of a high temperature, it was the presence of the tachycardia that prompted checking of the patient’s thyroid status. Delayed diagnosis of thyroid storm due to suppression of fever by DKA has been reported several times previously resulting in fatal outcomes 1,2. DKA was also high on the differential based on history and physical examination findings, being confirmed with initial labs showing elevated ketones, decreased P CO2 , bicarbonate and low pH combined with high glucose (table 1).…”

Section: Differential Diagnosismentioning

confidence: 74%

Simultaneous presentation of thyroid storm and diabetic ketoacidosis in a previously healthy 21-year-old man

Wallington

Schauer

Bauler³

2019

BMJ Case Rep

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A 21-year-old young man with no history of diabetes or thyroid disease presented to the emergency department with simultaneous thyroid storm and diabetic ketoacidosis. Notable findings on admission were a ventricular rate of 235 beats/min, tachypnoea, tremors, polydipsia and a lack of fever. Due to the unusual constellation of symptoms, diagnosis was only possible after initial laboratory results came back. While the lack of fever is unusual in thyroid storm, diabetic ketoacidosis has previously been reported to suppress fever, and this case supports the occurrence of this phenomenon. This case was highly unusual because the patient had not previously been diagnosed with either type 1 diabetes or Graves’ disease.

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Thyroid Crisis Associated with Diabetic Coma

Cited by 17 publications

References 19 publications

Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: A case report

Thyroid storm associated with Graves' disease covered by diabetic ketoacidosis: A case report

Coma in Thyroid Storm: Review of Aggregated English-Language Case Reports

Simultaneous presentation of thyroid storm and diabetic ketoacidosis in a previously healthy 21-year-old man

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