Type 2 Diabetes Decompensation as the Clinical Presentation of Thyroid Storm – Cause or Consequence?

Abstract

This case study aims to discuss the unusual forms of hyperthyroidism presentation, the nonspecific symptoms and precipitating events. A 70-year-old male was taken to the emergency department for hyperglycaemia, nausea, vomiting and altered mental status with a week of evolution. He had a past medical history of type 2 diabetes, hypertension and dyslipidemia. He had no history of any recent intercurrent illness or infection. At the emergency room, besides hyperglycaemia, ketonemia and slightly elevated C-reactive protein, the basic laboratory panel workup was normal, as was the head computed tomography. He was admitted for metabolic compensation and to study the altered neurological status. During hospitalisation, despite the good glycemic control, he had no improvements in neurological status. At day four of hospitalisation, thyrotoxicosis with thyroid storm criteria was diagnosed. He started on adequate treatment with complete clinical recovery. The associated morbidity and mortality of thyroid storm requires immediate recognition and treatment. Elderly patients are frequently misdiagnosed or diagnosed later due to fewer and less pronounced signs and symptoms.

Diabetic Ketoacidosis Associated with Thyroxine (T4) Toxicosis and Thyrotoxic Cardiomyopathy

“…Another clue in DKA patients that should lead physicians to suspect the possibility of thyrotoxicosis are: (1) the presence of goiter, and (2) persistent tachycardia in any type, with or without fever, even when other thyrotoxic features are absent. Our patient at admission did not present tachycardia, maybe due to profound high anion gap and non-anion gap metabolic acidosis (delta ratio 0.6 mEq/L and delta gap 12) [3,4,5,7,8,9]. The absence of fever, one of the “classical” signs of thyrotoxicosis, in this patient is remarkable.…”

“…Some studies have reported that 20 to 35% of patients with thyrotoxicosis or TS can have no identifiable precipitant factor [10,11,12,13]. To the clinician, the development of hyperthyroidism in a patient with preexisting DM is a situation that would generally be expected to lead to difficulties in controlling the DM and potentially to DKA may develop [7,8,9,15].…”

Thyroid Storm and Diabetic Ketoacidosis Presenting to the Emergency Department

“…The authors were fortunate that this patient was a reliable historian and had presented to our hospital previously; thus, her Graves' disease and diabetes mellitus were taken into account during her evaluation. This patient's presentation and triage vital signs indicated severe disease, though the initial presentation can be significantly more subtle in elderly patients or those unable to mount tachycardia secondary to beta-blockers [9]. Previous case reports have shown that one of the principle features of thyroid storm, fever, can be masked when both disease processes present together, making recognition even more difficult [10].…”

“…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].…”

Intractable hiccups as a rare gastrointestinal manifestation in severe endocrine and metabolic crisis: case report and review of the literature

“…11 The literature related to TS was searched from 2016 to 2019, and the clinical characteristics of gastrointestinal symptoms in patients with TS were found to mainly be nausea, and the main cause of TS to be Graves' disease with unknown or poor compliance with anti-thyroid drugs (Table 3). [33][34][35][36][37][38][39][40][41][42][43][44][45][46] Considering that hiccups are not common in either DKA or TS, we speculate that the incidence of intractable hiccups is rare when DKA overlaps with TS. By carefully searching the literature, we found the following related cases.…”