Case Presentation: 48-year-old-female with the history of Diabetes Mellitus presented with the complain of feeling sick for four-day-duration, chronic diarrhea, and unintentional weight loss of 20 lbs. over a period of two weeks. She was hypotensive with blood pressure 83/42 mmHg, hypothermic with temperature 35 C, tachycardic with the heart rate of 132 and tachypneic on presentation. Physical examination revealed mild thyromegaly, otherwise unremarkable. Chest X-ray did not show any consolidation. Laboratories were significant for hyperglycemia of 785 mg/dl, ketonemia with beta-hydroxy-butyrate of 4.7, neutrophilic leukocytosis with WBC 21.9.. Venous blood gas analysis showed well compensated metabolic acidosis with pH 6.96, bicarbonate of 5 mMol/L, anion gap of 20 mEq/L. Urine analysis was strongly positive for ketone and glucose, however, negative for leukocyte esterase or nitrite. Given the presence of hyperglycemia, anion gap metabolic acidosis and ketonemia, she was being treated in view of severe diabetic ketoacidosis with insulin drip and intravenous fluid. Other potential precipitating factors for DKA such as infection, myocardial infarction were ruled out. The trigger for DKA was thought to be non-adherence to insulin therapy. Despite appropriate transition to basal bolus subcutaneous insulin regimen once DKA resolved, the patient’s glycemic control, acidosis and anion gap worsened the following day. She developed fever with temperature of 38.4 C two days after admission without any evidence of infection. Since she had been persistently tachycardic, tachypenic and febrile, thyroid function test was performed, which revealed suppressed TSH of 0.005 uIU/ml, high free T4 of 2.5 ng/dl and thyroid stimulating immunoglobulin of 171%. Bedside Burch-Wartofsky Point Scale (BWPS) was calculated, found to be at 55, which was highly suggestive of thyroid storm. She was being treated for thyroid storm with lugol’s iodine, propylthiouracil propranolol, and hydrocortisone. Her condition and metabolic abnormality improved drastically, enabling her to be transferred out of the intensive care unit in next 48 hours.
Discussion: Thyroid storm and diabetic ketoacidosis are two endocrine emergencies, and simultaneous clinical presentation is rarely reported. Thyroid storm can precipitate DKA, the mechanisms involved are increased glucose absorption, enhanced hepatic glycogenolysis and gluconeogenesis, increased insulin resistance and clearance. On the other hand, poor glycemic control can alter thyroid function. However, because of overlapping symptoms and signs between DKA and thyroid storm, thyroid storm can be easily overlooked, especially in patient with no prior history.
Conclusions: As per one systematic review, published on May 2019, only 26 cases of concurrent thyroid storm and DKA were found globally so far. And the mortality rate was recorded to be as high as 15%. Although thyroid function is usually being deferred during acute illness, such screening would be essential in appropriate clinical setting. Moreover, bedside Burch-Wartofsky point scale is a very helpful tool in diagnosing thyroid storm, and can save patient from life-threatening situation. Even though, dietary and medication indiscretion seems to be the most common trigger for DKA, hyperthyroid as one of the precipitating factors for DKA should not be overlooked.