SUN-522 A Case of Diabetic Ketoacidosis Associated with Thyroid Storm

Abstract Background: Thyrotoxic crisis is a rare complication of diabetic ketoacidosis (DKA). We herein report a case of DKA and subsequent thyroid storm which required emergent tracheostomy possibly due to large goiter and post-intubation obstruction. Clinical Case: A 26-year-old woman was admitted to our emergency department complaining fever (38.2℃) and palpitation. There was no history of autoimmune disease. Physiological examination revealed tachycardia (pulse rate 164/min), tachypnea (55/min), impaired consciousness with a GCS score of 13 (E3V4M6) and goiter. Endotracheal intubation was performed. Her laboratory tests showed metabolic acidosis (pH 7.255), marked high plasma glucose of 1,672 mg/dL, elevated HbA1c of 9.2%, elevated FT3 and FT4 with suppressed TSH. She scored 55 on the diagnostic criteria for thyroid storm of Burch & Wartofsky. Based on these findings, she was diagnosed as having DKA and thyroid crisis. The patient responded well to standard treatment which involves intravenous insulin infusion with pump, correction of electrolyte disturbances, use of methimazole, as well as propranolol. Meanwhile, the patient was positive for anti-glutamic acid decarboxylase (GAD) antibody, TSH receptor antibody, as well as thyroid stimulating antibody, indicating type 1 diabetes and Graves’ disease. She underwent extubation on day 5, however, she developed wheezing around day 30. Imaging analysis demonstrated remarkable tracheal stenosis that is possibly due to large goiter and airway injury by intubation. Emergent tracheostomy was performed on day 50, because the dyspnea became progressively worse. Later, she was successfully treated by tracheal stent placement. At the follow-up period, the patient was found to be doing well, with no severe hyperthyroidism or changes in bronchoscopic findings. Conclusion: Thyroid storm is a rare but serious complication of DKA. Our report highlights the importance of considering airway obstruction due to large goiter especially in patients with a past history of prolonged ventilation.

Download Full-text

Coexistence of diabetic ketoacidosis and thyrotoxicosis: a jeopardy of two endocrine emergencies

BMJ Case Reports ◽

10.1136/bcr-2021-243534 ◽

2021 ◽

Vol 14 (6) ◽

pp. e243534

Author(s):

Soban Ahmad ◽

Amman Yousaf ◽

Shoaib Muhammad ◽

Fariha Ghaffar

Keyword(s):

Diabetes Mellitus ◽

Diabetic Ketoacidosis ◽

Clinical Presentation ◽

Early Recognition ◽

Favourable Outcome ◽

Adverse Outcomes ◽

Thyroid Storm ◽

Graves Disease ◽

Thyroid Disorders ◽

History Of

Simultaneous occurrences of diabetic ketoacidosis (DKA) and thyroid storm have long been known, but only a few cases have been reported to date. Both these endocrine emergencies demand timely diagnosis and management to prevent adverse outcomes. Due to the similarities in their clinical presentation, DKA can mask the diagnosis of thyroid storm and vice versa. This case report describes a patient with Graves’ disease who presented to the emergency department with nausea, vomiting and abdominal pain. He was found to have severe DKA without an explicit history of diabetes mellitus. Further evaluation revealed that the patient also had a concomitant thyroid storm that was the likely cause of his DKA. Early recognition and appropriate management of both conditions resulted in a favourable outcome. This paper emphasises that a simultaneous thyroid storm diagnosis should be considered in patients with DKA, especially those with a known history of thyroid disorders.

Download Full-text

Risk Factor Related to Mortality of Diabetic Ketoacidosis Patients in Dr. Soetomo General Hospital Surabaya

JUXTA: Jurnal Ilmiah Mahasiswa Kedokteran Universitas Airlangga ◽

10.20473/juxta.v11i12020.36-40 ◽

2020 ◽

Vol 11 (1) ◽

pp. 36

Author(s):

Alviano Satria Wibawa ◽

Hermina Novida ◽

Muhammad Faizi ◽

Deasy Ardiany

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Diabetic Ketoacidosis ◽

General Hospital ◽

Developed Countries ◽

Chi Square ◽

High Blood Glucose ◽

Electrolyte Disturbances ◽

Chi Square Test ◽

History Of

Introduction: Diabetic ketoacidosis (DKA) is a complication of diabetes mellitus which has a high risk of mortality. Mortality in DKA patients in developed countries is less than 5%, some other sources mention 5-10%, 2-10%, or 9-10%. Mortality events at clinics with simple facilities and elderly patients can reach 25-50%. The mortality rate of DKA patients is generally higher in infection conditions, especially in developing countries and in septic patients. Several factors such as age, sex, and high blood glucose can increase mortality risk of DKA patients. Other risk factors such as history of discontinued insulin therapy, impaired bicarbonate levels, pH, and increased leukocytes of DKA patients due to infection, abnormal albumin levels, electrolyte disturbances, and Serum Creatinine (SK) were thought to affect mortality of DKA patients. The purpose of this study was to determine the risk factors associated with mortality of DKA patients in Dr. Soetomo General Hospital Surabaya. Methods: The method used in this study was observational analytic involving 63 adult patients diagnosed with DKA with analysis using Chi-Square test. Results: From 63 patients included in this study, 37 patients diagnosed with DKA died and 26 patients lived. In a multivariate analysis, DKA severity with p = 0.001 (p < 0.005) was identified as having a relationship with mortality of DKA patients Dr. Soetomo General Hospital Surabaya. Conclusion: Severity is the only risk factor associated with mortality of DKA patients in Dr. Soetomo General Hospital Surabaya.

Download Full-text

Hyperglycaemia, diabetes, and other endocrine emergencies

10.1093/med/9780199687039.003.0069 ◽

2015 ◽

Author(s):

Yves Debaveye ◽

Dieter Mesotten ◽

Greet Van den Berghe

Keyword(s):

Intensive Care ◽

Diabetic Ketoacidosis ◽

Specific Treatment ◽

Blood Glucose Monitoring ◽

Thyroid Storm ◽

Adrenal Crisis ◽

Complex Disorders ◽

State Management ◽

Electrolyte Disturbances ◽

Life Threatening

Although endocrine pathology is usually treated in outpatient clinic, intensive care may be required when endocrinopathies are associated with other medical illnesses or reach a state of decompensation. Although endocrine emergencies are quite rare, they are potentially life-threatening, if not recognized promptly and managed effectively. Therefore, every clinician should always be attentive to a possible diagnosis of these complex disorders. The three major diabetic emergencies comprise diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and prolonged hypoglycaemia. Hyperglycaemic crises are characterized by hypovolaemia, electrolyte disturbances, and potentially life-threatening triggers. Hence, airway-breathing-circulation securement, diagnosis and treatment of the underlying condition, and fluid resuscitation are the cornerstones of acute diabetic ketoacidosis/hyperglycaemic hyperosmolar state management. Subsequently, monitoring and correction of electrolyte disturbances and insulin treatment are initiated. Profound hypoglycaemia should be suspected in every coma patient with an indistinct history or treated with insulin or sulfonylurea/meglitinide. This condition warrants an immediate and a sufficiently long administration of glucose, under blood glucose monitoring. Alternatively, glucagon may be injected subcutaneously, or preferably intramuscularly. Hyperglycaemia in intensive care unit patients is associated with adverse outcome which can be prevented via the implementation of glucose control with intravenous insulin. One should hereby target glucose levels to be as close to normal as possible, without evoking unacceptable glucose fluctuations and hypoglycaemia. The classical non-diabetic endocrine emergencies comprise thyroid storm, myxoedema coma, acute adrenal crisis, and phaeochromocytoma. They all pose diagnostic and therapeutic challenges and require specific treatment such as endocrine replacement or blockage therapy. It is important to note that they are occasionally the presenting manifestation in undiagnosed patients. This chapter also briefly discusses amiodarone-induced thyroid dysfunction.

Download Full-text

Bilateral Chronic Subdural Hematoma and Blindness: Bilateral Infarction to the Posterior Cerebral Artery following Evacuation of Bilateral Chronic Subdural Hematoma — A Rare Case Report and Review of Literature

Indian Journal of Neurotrauma ◽

10.1055/s-0037-1604052 ◽

2017 ◽

Vol 14 (01) ◽

pp. 046-052

Author(s):

Sendilkumar Adimoolam ◽

Syamala Shunmugam ◽

Sneha Balasubramanian

Keyword(s):

Subdural Hematoma ◽

Past History ◽

Rare Complication ◽

Chronic Subdural Hematoma ◽

Vascular Abnormality ◽

Rare Case Report ◽

History Of ◽

Burr Holes ◽

Bilateral Chronic Subdural Hematoma ◽

Ct And Mri

Objective The authors report a rare scenario in which evacuation of bilateral chronic subdural hematoma (CSDH) was followed by bilateral PCA infarction and blindness. A literature review was also conducted, which revealed only four cases of blindness after CSDH evacuation. Methods A 45-year-old man was admitted with the chief complaint of holocranial headache for 2 months with past history of head trauma. Clinical examination was normal. CT and MRI scanning showed bilateral frontotemperoparietal CSDH without midline shift and parenchymal and vascular abnormality. Bilateral frontal and parietal burr holes and evacuation of CSDH was done. Results The patient developed progressive blindness in both the eyes in the postoperative period. MRI revealed bilateral PCA infarction. Discussion Bilateral PCA infarction following bilateral CSDH evacuation is an extremely rare entity. Only four case of blindness following CSDH evacuation have been reported so far, and all the patients suffered permanent visual loss. The exact etiopathogenesis and mechanism of this rare complication remain unknown. Conclusion Bilateral CSDH is a separate entity with altered pathophysiology and deranged cerebral autoregulation. The authors conclude that Bilateral CSDH may be sentinel tags for bilateral PCA infarction secondary to altered hemodynamics in the posterior circulation, and hence, needs to be evaluated and treated with greater diligence.

Download Full-text

Prevalence and Associated Factors of Diabetic ketoacidosis among Patients Living with Type 1 Diabetes in Makkah Al-Mukarramah City

10.5742/mewfm.2021.94154 ◽

2021 ◽

Vol 20 (11) ◽

Author(s):

Raghad Alhajaji ◽

Khalid Almasodi ◽

Afaf Alhajaji ◽

Ahmad Alturkstani ◽

Mayada Samkari

Keyword(s):

Risk Factors ◽

Type 1 Diabetes ◽

Diabetic Ketoacidosis ◽

Hba1c Level ◽

Past History ◽

Postgraduate Education ◽

Cross Sectional ◽

Female Patients ◽

History Of

Objective: To assess magnitude of diabetic ketoacidosis (DKA) among type-1 diabetics and to identify associated risk factors. Methods: A cross-sectional study was conducted among 236 type-1 diabetics in Makkah Al-Mukarramah City, Saudi Arabia. Results: Among participants, 59.3% were males, 44.1% were diabetic for more than 5 years, while 70.8% reported past history of DKA. The main causes of DKA were gfirst presentation of the diseaseh (40.9%), and gdiscontinued treatmenth (37%). The HbA1c among 53.6% was above 9%. Almost all cases who experienced DKA were hospitalised (98.8%). Out of them, 9 (5.4%) suffered complications. Female patients were more likely to suffer from episodes of DKA than males (76% and 68.3%, respectively). Most patients whose parentsf highest education was primary level had DKA more frequently than those whose parentsf had postgraduate education. Patients with unemployed fathers had significantly higher frequency of DKA (p=0.004). Ketoacidosis was significantly more frequent among patients with parentsf consanguinity (p<0.001). Patients who had their current HbA1c level exceeding 9% had positive history of DKA compared to those with HbA1c level .7% (87.9% and 28.6%, respectively, p<0.001). Conclusion: Most type-1 diabetics experience DKA, mainly with their first presentation of disease or due to discontinuation of treatment. DKA tends to occur more frequently among female patients, those with less educated parents or when their parents are relatives. Key words: Type 1 diabetes, diabetic ketoacidosis, magnitude, risk factors.

Download Full-text

Prevalence and Associated Factors of Diabetic ketoacidosis among Patients Living with Type 1 Diabetes in Makkah City

10.1101/2021.10.28.21264912 ◽

2021 ◽

Author(s):

Raghad Alhajaji ◽

Khalid Almasodi ◽

Afaf Alhajaji ◽

Ahamd Alturkistani ◽

Mayada Samkari

Keyword(s):

Diabetic Ketoacidosis ◽

Hba1c Level ◽

Past History ◽

Postgraduate Education ◽

Cross Sectional Study ◽

Cross Sectional ◽

Female Patients ◽

History Of ◽

Associated Risk Factors

Objective: To assess magnitude of diabetic ketoacidosis (DKA) among type-1 diabetics and to identify associated risk factors. Methods: A cross-sectional study was conducted among 236 type-1 diabetics in Makkah Al-Mukarramah City, Saudi Arabia. Results: Among participants, 59.3% were males, 44.1% were diabetic for more than 5 years, while 70.8% reported past history of DKA. The main causes of DKA were first presentation of the disease (40.9%), and discontinued treatment (37%). The HbA1c among 53.6% was above 9%. Almost all cases who experienced DKA were hospitalised (98.8%). Out of them, 9 (5.4%) suffered complications. Female patients were more likely to suffer from episodes of DKA than males (76% and 68.3%, respectively). Most patients whose parents' highest education was primary level had DKA more frequently than those whose parents' had postgraduate education. Patients with unemployed fathers had significantly higher frequency of DKA (p=0.004). Ketoacidosis was significantly more frequent among patients with parents' consanguinity (p<0.001). Patients who had their current HbA1c level exceeding 9% had positive history of DKA compared to those with HbA1c level 7% (87.9% and 28.6%, respectively, p<0.001). Conclusion: Most type-1 diabetics experience DKA, mainly with their first presentation of disease or due to discontinuation of treatment. DKA tends to occur more frequently among female patients, those with less educated parents or when their parents are relatives.

Download Full-text

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

Medicina ◽

10.3390/medicina54060093 ◽

2018 ◽

Vol 54 (6) ◽

pp. 93

Author(s):

Edinson Meregildo Rodriguez ◽

Luis Gordillo Velásquez ◽

José Alvarado Moreno

Keyword(s):

Diabetic Ketoacidosis ◽

Left Ventricular Systolic Dysfunction ◽

Past History ◽

Systolic Dysfunction ◽

Left Ventricular ◽

The Other ◽

Elevated Troponin ◽

Ventricular Systolic Dysfunction ◽

History Of ◽

Appropriate Therapy

Thyrotoxicosis and diabetic ketoacidosis (DKA) both may present as endocrine emergencies and may have devastating consequences if not diagnosed and managed promptly and effectively. The combination of diabetes mellitus (DM) with thyrotoxicosis is well known, and one condition usually precedes the other. Furthermore, thyrotoxicosis is complicated by some degree of cardiomyopathy in at least 5% de patients; but the coexistence of DKA, thyroxin (T4) toxicosis, and acute cardiomyopathy is extremely rare. We describe a case of a man, previously diagnosed with DM but with no past history of thyroid disease, who presented with shock and severe DKA that did not improve despite optimal therapy. The patient evolved with acute pulmonary edema, elevated troponin levels, severe left ventricular systolic dysfunction, and clinical and laboratory evidence of thyroxin (T4) toxicosis and thyrotoxic cardiomyopathy. Subsequently, the patient evolved favorably with general support and appropriate therapy for DKA and thyrotoxicosis (hydrocortisone, methimazole, Lugol’s solution) and was discharged a few days later.

Download Full-text

A Case of Psychosis in Disulfiram Treatment for Alcoholism

Case Reports in Psychiatry ◽

10.1155/2014/561092 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

Raquel Calvão de Melo ◽

Rui Lopes ◽

José Carlos Alves

Keyword(s):

Psychiatric Illness ◽

Past History ◽

Rare Complication ◽

Chronic Alcoholism ◽

Physical Symptoms ◽

Psychotic Symptoms ◽

Alcohol Dependency ◽

Mesolimbic System ◽

History Of

Background. Disulfiram, a drug used in the treatment of alcohol dependence, is an inhibitor of dopamine-β-hydroxylase causing an increase in the concentration of dopamine in the mesolimbic system. In addition to the physical symptoms associated with concomitant use of alcohol, disulfiram may lead to adverse events, when used alone, including psychosis.Aims. To report a case of a rare complication when using disulfiram for alcoholism treatment in a patient in alcoholic abstinence.Case Report. We describe the case of a 42-year-old male patient, who developed psychotic symptoms 3 weeks after initiating treatment with disulfiram for alcohol dependency. The patient had a history of chronic alcoholism for 12 years and was under disulfiram treatment (250 mg/day) for 1 month, with no other past history of psychiatric illness. The symptoms worsened after he initiated alcohol consumption, while taking disulfiram. The patient was hospitalized and disulfiram was suspended. After 4 days he was asymptomatic and at 6-week follow-up remained asymptomatic.Conclusion. Treatment with disulfiram can lead to the appearance of psychosis in patients with increased vulnerability. In clinical practice, psychosis in the context of alcoholism with disulfiram therapy is often neglected and should be taken into account.

Download Full-text

The World Anti-Doping Code: can you have asthma and still be an elite athlete?

Breathe ◽

10.1183/20734735.004116 ◽

2016 ◽

Vol 12 (2) ◽

pp. 148-158 ◽

Cited By ~ 7

Author(s):

Ken Fitch

Keyword(s):

Elite Athletes ◽

Past History ◽

List Type ◽

Intensive Training ◽

Airway Injury ◽

Key Points ◽

The World ◽

History Of ◽

Inhaled Glucocorticoids ◽

Intravenous Glucocorticoids

Key pointsThe World Anti-Doping Code (the Code) does place some restrictions on prescribing inhaled β2-agonists, but these can be overcome without jeopardising the treatment of elite athletes with asthma.While the Code permits the use of inhaled glucocorticoids without restriction, oral and intravenous glucocorticoids are prohibited, although a mechanism exists that allows them to be administered for acute severe asthma.Although asthmatic athletes achieved outstanding sporting success during the 1950s and 1960s before any anti-doping rules existed, since introduction of the Code’s policies on some drugs to manage asthma results at the Olympic Games have revealed that athletes with confirmed asthma/airway hyperresponsiveness (AHR) have outperformed their non-asthmatic rivals.It appears that years of intensive endurance training can provoke airway injury, AHR and asthma in athletes without any past history of asthma. Although further research is needed, it appears that these consequences of airway injury may abate in some athletes after they have ceased intensive training.The World Anti-Doping Code (the Code) has not prevented asthmatic individuals from becoming elite athletes. This review examines those sections of the Code that are relevant to respiratory physicians who manage elite and sub-elite athletes with asthma. The restrictions that the Code places or may place on the prescription of drugs to prevent and treat asthma in athletes are discussed. In addition, the means by which respiratory physicians are able to treat their elite asthmatic athlete patients with drugs that are prohibited in sport are outlined, along with some of the pitfalls in such management and how best to prevent or minimise them.

Download Full-text

Thyroid Storm: A Dreaded Complication of Percutaneous Tracheostomy

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1970 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A963-A964

Author(s):

Pallavi Pradeep ◽

Mohammed Hussain Kazi

Keyword(s):

Mechanical Ventilation ◽

Rare Complication ◽

Percutaneous Tracheostomy ◽

Clinical Status ◽

Thyroid Storm ◽

First Case ◽

Surgical Tracheotomy ◽

History Of ◽

American Society

Abstract Background: Thyroid gland may be manipulated during tracheostomy. Although uncommon, this may result in potentially life-threatening thyroid storm especially in patients with underlying thyroidal illness. Plasmapheresis maybe used as a treatment modality for these patients. Clinical Case: A 65-year-old Hispanic male was admitted to the hospital for acute exacerbation of heart failure and pneumonia. Medical history was significant for atrial fibrillation. He had been on amiodarone for 2 years, which was discontinued 2 months ago when he was diagnosed with amiodarone indued thyrotoxicosis (AIT). He was never started on any treatment for AIT. Lab work on admission was significant for undetectable TSH, fT4 of 4.4 ng/ml (RR: 0.8-1.5 ng/ml) and fT3 of 4pg/ml (RR: 2.2- 4.0 pg/ml). TSH receptor antibody was negative. Thyroid ultrasound showed mildly atrophic gland with no nodules. Methimazole, cholestyramine and hydrocortisone were initiated, and TFTs were trending down. Hospital course was complicated by cardio-respiratory failure requiring mechanical ventilation. After a short-term improvement in his clinical status, patient underwent percutaneous tracheotomy due to failure to wean from mechanical ventilation. On POD1, he was found to be tachycardic and febrile with Burch-Wartofsky score of 55, which was highly suggestive of thyroid storm. fT4 was >8ng/ml and fT3 was 11.4pg/ml. He did not respond to maximal doses of thionamides, steroids and b-blocker. Thyroidectomy was considered, but patient was deemed to be high risk for any surgical intervention. Plasmapheresis was initiated for 5 days. TFT started trending down and patient improved clinically. On POD 14, fT4 was 2.1ng/ml, fT3 was 3.8 pg/ml. Conclusion: This case highlights a rare complication of tracheostomy in a patient with known history of AIT. Studies have shown that there can be a significant increase in serum thyroid hormone levels after tracheostomy, even in euthyroid patients. There may even be a role of performing tracheostomy with thyroidectomy in non-euthyroidal patients. Use of plasmapheresis for thyroid storm is recommended by American Society of Apheresis when first line medical therapy fails. It maybe particularly effective in AIT as amiodarone and its active metabolite are highly bound to plasma proteins. To our knowledge, this is the first case of thyroid storm with a history of AIT, which was precipitated by tracheostomy, and successfully treated with plasmapheresis. References: 1. Esen E, Karaman M, Deveci I, Tatlıpınar A, Tuncel A, Sheidaei S, Esen S. Analysis and comparison of changing in thyroid hormones after percutaneous and surgical tracheotomy. Auris Nasus Larynx. 2012 Dec;39(6):601-5.2. Muller C, Perrin P, Faller B, Richter S, Chantrel F. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec;15(6):522-31.

Download Full-text