Thyroid storm presenting as psychosis: masked by diabetic ketoacidosis

Abstract

IntroductionWhile extremely uncommon, diabetic ketoacidosis (DKA) and thyroid storm (TS) are endocrine emergencies that can coexist. We describe a case with a confounding clinical presentation that identifies these two emergencies within the setting of sepsis and influenza.CaseA 69-year-old diabetic female was found by the paramedic staff to be disoriented. She demonstrated tachycardia and had a foul-smelling abdominal wound. Laboratory evaluation revealed DKA, leukocytosis, influenza B, and urinary tract infection. After appropriate management in the intensive care unit, the DKA resolved the following morning. However, the patient developed a fever, and her psychosis became more pronounced. Extensive analysis was performed but did not explain her mental status. The patient was found to have thyroid stimulating hormone of 0.06 mIU/mL, free T4 (thyroxine) of 2.38 ng/dL, and total T3 (triiodothyronine) of 72 ng/dL. Based on the Burch and Wartofsky criteria (score of 65), TS was diagnosed. Based on more recent diagnostic criteria suggested by Akamizu et al., the patient met criteria for TS grade 1. Within several hours of initiating treatment, the patient's mental state and tachycardia improved, and her psychosis resolved by the third day.ConclusionThis case highlights the importance of recognizing the clinical diagnosis of TS, as the magnitude of thyroid hormone derangements may not correlate with clinical severity. While rare, DKA and TS can simultaneously occur and are associated with increased morbidity and mortality if not promptly recognized and treated.

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].…”

“…One case report diagnosed DKA and thyroid storm in a patient without previous history of diabetes mellitus or thyroid disease [7]. Another published in 2016 described DKA and thyroid storm presenting as acute psychosis [8]. A systematic review of 21 cases of concomitant DKA and thyroid storm published in 2019 examined current literature and found many risk factors associated with both conditions, but it was unable to definitively link cause and effect of both conditions [5].…”

Case Report: Occurrence of Thyroid Storm in a Young Patient With Recurrent Diabetic Ketoacidosis

“…Previous reports have confirmed the co-occurrence of DKA and thyroid crisis. However, owing to its rarity, its clinical course remains unclear ( 9 , 10 ). In this study, we present a rare case of TS in a young man with recurrent DKA.…”

Thyroid storm presenting as septic shock in the intensive care unit: A Case Series

“…Thyroid storm is a rare metabolic disease with incidence of 0.2/1,000,000 per year. 1 It is a medical emergency mimicking sepsis and septic shock due to multiple organ failure, often associated with triggering illness. Septic shock is a multi-system disease that can have similar presentation and can co-exist with thyroid storm that requires early diagnosis to decrease mortality and morbidity.…”