Endocrine Abstracts

Introduction: Thyroid storm is a rare condition, reflecting an extreme physiological state within the spectrum of thyrotoxicosis. The disorder consists of the clinical manifestations of thyrotoxicosis in association with altered mental status. On the other hand, excess circulating thyroid hormones are associated with glycemic disorders, like hyperglycemia and insulinopenia. Moreover, diabetic ketoacidosis has been associated with thyroid storm in few cases. We report the case of a patient who developed hyperglycemic hyperosmolar state (HHS) and thyroid storm.

Case report: A 77-year-old woman with history of diabetes mellitus presented complaining for nausea, vomiting, dry cough and epigastric sensation for 3 days of duration. The clinical examination revealed slight disturbance of consciousness, 40 breaths/min, 140 bpm and temperature of 37.4 °C. The chest X-ray and the urine sample were negative for infection, while the electrocardiogram showed sinus tachycardia. Laboratory studies revealed random blood glucose levels 814 mg/dl and mild metabolic acidosis, compatible with HHS. Hyperglycemia resolved rapidly after i.v. administration of normal saline and insulin, but the clinical signs remained unaffected. Additionally, the patient developed acute psychotic syndrome after 72 h. Laboratory data revealed thyrotoxicosis (TSH=0.005 μIU/ml, FT₄=5.19 ng/dl), after which the patient admitted previous noncompliance to the treatment. Thyroid storm was diagnosed at this point, with a score of 70 points according to the thyroid storm score by Burch and Wartofsky. The symptoms resolved after administration of thiamazole 60 mg and atenolol 50 mg, daily.

Discussion: Thyroid storm should be diagnosed immediately using clinical criteria, in order to improve outcomes. An upper respiratory tract infection was the only apparent precipitating factor, inducing the development of both HHS and thyroid storm. However, a direct interaction between the two conditions cannot be ruled out, especially due to their simultaneous occurrence.