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Year : 2014  |  Volume : 2  |  Issue : 4  |  Page : 177-179

Severe diabetic ketoacidosis and acute pericarditis precipitated by concomitant Graves' thyrotoxicosis in type 1 diabetic patient

Department of Endocrinology, King Fahad Armed Forces Hospital, Jeddah, Kingdom of Saudi Arabia

Date of Web Publication13-Oct-2014

Correspondence Address:
Muneera A Alshareef
Department of Endocrinology, King Fahad Armed Forces Hospital, Jeddah
Kingdom of Saudi Arabia
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DOI: 10.4103/1658-600X.142790

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20-year-old male known case of type 1 diabetes mellitus (T1DM) presented to emergency department with vomiting and abdominal pain, and was diagnosed to have diabetic ketoacidosis (DKA). There was no obvious precipitating cause for DKA. Patient was started on DKA protocol and initially responded well to treatment. Later on, patient developed severe metabolic acidosis and chest pain. The cardiac evaluation established the diagnosis of acute pericarditis and ruled out acute coronary syndrome. The cause for his stormy coarse of DKA, and persistent tachycardia were further evaluated, and he was diagnosed to have concomitant thyrotoxicosis (graves' disease) complicating the DKA. He was successfully treated with aggressive management of DKA and started on thyrotoxicosis treatment. Autoimmune diseases are known to manifest in cluster but concomitant thyrotoxicosis precipitating DKA and causing acute pericarditis is rare. Prompt recognition of thyrotoxicosis in patients with persistent tachycardia, and treatment of thyrotoxicosis will improve outcome in DKA patients.

Keywords: Acute pericarditis, diabetic ketoacidosis, type 1 diabetes, thyrotoxicosis

How to cite this article:
Alshareef MA, Khan PM, Bokhari S, El Saoud HA. Severe diabetic ketoacidosis and acute pericarditis precipitated by concomitant Graves' thyrotoxicosis in type 1 diabetic patient. J Health Spec 2014;2:177-9

How to cite this URL:
Alshareef MA, Khan PM, Bokhari S, El Saoud HA. Severe diabetic ketoacidosis and acute pericarditis precipitated by concomitant Graves' thyrotoxicosis in type 1 diabetic patient. J Health Spec [serial online] 2014 [cited 2020 Nov 29];2:177-9. Available from: https://www.thejhs.org/text.asp?2014/2/4/177/142790

  Introduction Top

Autoimmune endocrine conditions are common. The coexistence of type 1 diabetes mellitus (T1DM) and thyrotoxicosis (Graves' disease) is well-described in literature; one endocrinopathy usually precede the other. We describe an interesting case of concomitant thyrotoxicosis destabilizing diabetes control leading to severe diabetes ketoacidosis and acute pericarditis in a 20-year-old known type 1 diabetic patient. Control of blood glucose is warranted when examining thyrotoxicosis in patients presenting with unexplained diabetic ketoacidosis (DKA), especially if the patient remains tachycardic in spite of adequate intravenous fluids. Timely detection and prompt treatment of thyrotoxicosis prevents potential serious complications.

  Case Report Top

A 20-year-old man known case of T1DM of 8 years duration on pre-mix insulin treatment presented to the emergency room (ER) feeling unwell with nausea, abdominal pain, polyuria and polydipsia of 1 day duration. There was no history of any obvious triggering factor for DKA. On examination in the ER, he was conscious and oriented but dehydrated, pulse rate was 130/minute and regular, blood pressure (BP) (95/60 mm/Hg), temperature was 37 C, oxygen saturation was 99% at room air, and findings on cardiovascular system (CVS), respiratory system and central nervous system examinations were all normal. The abdomen was soft and bowel sounds were present. Initial laboratory investigations were listed in [Table 1].
Table 1: Laboratory investigations on admission

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Admission diagnosis of DKA was confirmed and patient was started on intravenous fluids, insulin infusion and potassium supplements as needed according to the DKA protocol of the institute. Patient showed improvement, blood sugar levels decreased, anionic gap and bicorbonate (HCO3) also improved. Six hours after admission while still on DKA protocol patient became agitated and complained about of central chest pain which was sharp in character and worse on deep inspiration. On examination patient was drowsy, pulse rate was 120/minute, BP was 100/66 mm/Hg, and CVS examination was normal with no pericardial friction rub. Follow up investigations were shown in [Table 2] and [Figure 1]
Figure 1: EKG showing ST elevation in LI.II,III,AVF, V2-6 (Uploaded as ECG.tif)

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Table 2: Laboratory Investigations after six hours follow-up

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Patient was started on aggressive intravenous fluid replacement and insulin infusion. Cardiac consultation was sought and echocardiogram (ECHO) performed revealed normal left ventricular size and function. No wall motion abnormalities were detected and subsequent coronary angiogram showed normal coronaries; a final diagnosis of acute pericarditis was made by the cardiologist. Patient's DKA was resolved however tachycardia persisted. On further evaluation of the underlying cause of tachycardia, a mild diffuse thyromegaly (Χ2) and fine tremor was revealed. The thyroid function test showed thyroid stimulating hormone (TSH) of 0.006 U/ml, free thyroxine (FT4) of 47.6 ng/dl and the TSH receptor antibodies were high confirmining the diagnosis of Graves' disease. Patient was started on betablockers and neomercazole which subsided the tachycardia. He was shifted to subcutaneous insulin with properly controlled blood glucose. He was discharged with further follow-up in the outpatient clinics.

  Discussion Top

The association between T1DM and Graves' thyrotoxicosis is well-documented in the medical literature. The prevalence of hyperthyroidism in T1DM may be as high as 12%. [1] Both diseases may coexist although one endocrinopathy usually precedes the other. The changes in intermediary glucose metabolism in thyrotoxicosis is well-known. [2] Hyperthyroidism is typically associated with worsening of glucose control, increased insulin requirement. Deterioration of diabetic control with onset of hyperthyroidism could have been due to enhancement of hepatic gluconeogenesis, rapid glucose absorption from intestine and insulin resistance. The simultaneous new onset of T1DM presenting with DKA and Graves' thyrotoxicosis is rare. Around four such cases have been reported in the medical literature review. [3],[4],[5],[6] The combination of these two diseases may lead to fatalities if not recognized and treated promptly. [7],[8] The concurrent onset of acute Graves' thyrotoxicosis in preexisting T1DM precipitating and complicating DKA is also rarely reported. [9],[10] Our case, was an interesting and rare case of T1DM presenting with DKA without any known triggering factor. In spite of appropriate treatment, he had a stormy course with initial improvement followed by relapse into severe DKA and also developed acute pericarditis. The typical history of chest pain, serial ECG changes, and ECHO with normal coronaries confirms the diagnosis of pericarditis. The moderate increase in our patient's cardiac enzymes could have been due to membrane instability and biomarker leakage from severe acidosis and high levels of fatty acids.In our case, DKA, resolved with aggressive management using intravenous fluids and insulin. The persistent tachycardia was investigated further and a diagnosis of Graves' thyrotoxicosis was confirmed. Acute pericarditis is rarely seen as a complication in DKA and thyrotoxicosis; its pathogenesis is debatable in this case. Myriads of ECG changes such as ST elevation/depression, alteration in T wave morphology and QT interval prolongation has been described frequently in DKA. Acute pericarditis was reported rarely in DKA. [11],[12] Severe acidosis and dehydration injury may cause pericardial injury and pericarditis. The pericarditis could be a complication of thyrotoxicosis, which was reported in several cases. [13],[14],[15],[16] The acute pericarditis is usually attributed to autoimmune mechanism but acute pericarditis occurring during acute thyrotoxic phase may be explained by direct metabolic impact leading to alterations in pericardial fat metabolism. [17]

DKA is a medical emergency in T1DM patients which may have fatal complications if not managed effectively. If a known triggering factor is not identified and patient remains persistently tachycardic, other coexisting illness such as thyrotoxicosis should be looked for and treated if present to avoid complications.

  References Top

1.Patricia WU. Thyroid disease and diabetes. Clin Diabetes 2000;18.  Back to cited text no. 1
2.Bratusch-Marrain PR, Kanjasi M, Waldausl WR. Glucose metabolism in non-insulin dependent diabetic patient with experimental hypoglycemia. J Clin Endocrinol Metab 1985;60:1063-8.  Back to cited text no. 2
3.Gupta S, Kandpal SB. Case report: Storm and acid together…! Am J Med Sci 2011;342:533-4.  Back to cited text no. 3
4.Osada E, Hiroi N, Sue M, Masai N, Iga R, Shigemitsu R, et al. Thyroid strom associated with Graves disease covered by diabetic ketoacidosis: A case report. Thyroid Res 2011;4:8.  Back to cited text no. 4
5.Mercer V, Burt V, Dhatariya UK. New onset type 1 diabetes presenting as ketoacidosis simultaneously presenting with autoimmune hyperthyroidism - a case report. J Diabetes Complications 2011;25:208-10.  Back to cited text no. 5
6.Bridgman JF, Pett S. Simultaneous presentation of thyrotoxic crisis and diabetic ketoacidosis. Postgrad Med J 1980;56:354-5.  Back to cited text no. 6
7.Lin CH, Chen SC, Lee CC, Ko PC, Chen WJ. Thyroid strom concealing Diabetic ketoacidosis leading to cardiac arrest. Resuscitation 2004;63:345-7.  Back to cited text no. 7
8.Yeo KF, Yang YS, Chen KS, Peng CH, Huan CN. Simultaneous presentation of thyrotoxicosis and diabetic ketoacidosis result in sudden cardiac arrest. Endocr J 2007;54:991-3.  Back to cited text no. 8
9.Bhattacharyya A, Wiles PG. Diabetic ketoacidosis precipitated by thyrotoxicosis. Postgrad Med J 1999;75:291-2.  Back to cited text no. 9
10.Sola E, Morillas C, Garzon S, Gomez-Balagner M, Hernandez-Mijares A. Association between diabetes ketoacidosis and thyrotoxicosis. Acta Diabetol 2002;39:235-7.  Back to cited text no. 10
11.Roger D, Rolle F, Teissier MP, Mansset J, Archanbeand- Mouveronx F, Lanbie B. Acute percarditis during acute diabetic metabolic decompensation. Presse Med 1994;23:299.  Back to cited text no. 11
12.Manrique Franco K, Aragon Valera C, Gutierez Medina S, Sanchez-Vilar Burdiel O, Rovira Loscos A. Acute pericarditis associated to onset of diabetes mellitus. Endocrinol Nutr 2012;59:608-9.  Back to cited text no. 12
13.Clarke NR, Banning AP, Gwilt AJ, Scott AR. Pericardial disease associated with Graves thyrotoxicosis. QMJ 2002;95:188-9.  Back to cited text no. 13
14.Sugar ST. Pericarditis as a complication of thyrotoxicosis (Letter). Ann Int Med 1981;141:42.  Back to cited text no. 14
15.Inami T, Seiro Y, Goda H, Okazaki H, Shirakabe A, Yamamoto M, et al. Acute pericarditis: Unique comorbity of thyrotoxic crisis with Graves' disease. Int J Cardiol 2014;171:e129-30.  Back to cited text no. 15
16.Tsai MS, Yang CW, Chi CL, Hsieh CC, Chen WJ, Huang CH. Acute pericarditis: A rare complication of Graves' thyrotoxicosis. Am J Emerg Med 2006;24:374-5.  Back to cited text no. 16
17.Chabbra L, Spodick DH. A comment on thyrotoxic pericarditis. Int J Cardiol 2014;173:587.  Back to cited text no. 17


  [Figure 1]

  [Table 1], [Table 2]

This article has been cited by
1 Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases
Devarajan Rathish,Senuri Karalliyadda
BMC Endocrine Disorders. 2019; 19(1)
[Pubmed] | [DOI]


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