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

Abstract

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.

Hyperthyroidism in 276 Children and Adolescents with Type 1 Diabetes from Germany and Austria

“…High L -thyroxine levels have been reported to enhance glucose uptake, hepatic gluconeogenesis, and insulin resistance and to increase lipase activity, resulting in higher lipolysis and eventually contributing to DKA or chronic hyperglycemia [10]. …”

“…In most cases, GD is diagnosed years after diabetes onset [3], but there are also reports of GD onset before or concurrently with the diagnosis of diabetes [8,9,10]. …”

“…Thyrotoxicosis is also reported to trigger diabetic ketoacidosis (DKA). Thus, in the absence of other factors, thyrotoxicosis should be considered as a cause of DKA [10,9]. On the other hand, DKA might mask the symptoms of hyperthyroidism and GD [4].…”

Thyroid Storm and Diabetic Ketoacidosis Presenting to the Emergency Department

“…Previous literature has explored the relationship between thyroid storm and DKA, but to date no case reports have been published in a patient with an insulin pump. This leads to an important question of whether DKA or thyroid storm was the consequence or the precipitating factor [4,[6][7][8][9][10]. One case report diagnosed DKA and thyroid storm in a patient without previous history of diabetes mellitus or thyroid disease [7].…”

Review article: Ketoacidosis in the emergency department

“…Catecholamine excess results in inhibition of pancreatic insulin release, increased hepatic glucose output and reduced skeletal muscle glucose uptake . Thyrotoxicosis is associated with adrenergic‐driven increase in insulin resistance, increased insulin clearance, reduced skeletal muscle uptake of glucose, increased lipase activity and increased glycogenolysis …”