28090049 Visualization

A 46 Age - year Age - old Age woman Sex with a history of Graves' History disease History (GD) History was transferred Clinical_event to our emergency Nonbiological_location department Nonbiological_location on suspicion of DKA Disease_disorder .
She had noticed polydipsia Sign_symptom , polyuria Sign_symptom , and fatigue Sign_symptom approximately four Duration months Duration prior Duration to Duration admission Duration .
She had also been suffering from a 1 Duration - month Duration complaint of appetite Sign_symptom loss Sign_symptom , approximately 7 Lab_value kg Lab_value weight Sign_symptom loss Sign_symptom , fatigue Sign_symptom , nausea Sign_symptom , and sweating Sign_symptom .
Her medical history included GD Disease_disorder , diagnosed Date at Date 42 Date years Date of Date age Date and History managed History with History methimazole History .
However, she had poor Lab_value compliance Lab_value with anti Medication - thyroid Medication drugs Medication .
She denied History a History family History history History of History thyroid History diseases History or History diabetes History .
Three Date days Date before Date admission Date , she was also diagnosed Clinical_event with influenza Disease_disorder A Disease_disorder at a nearby Nonbiological_location hospital Nonbiological_location , and oseltamivir Medication phosphate Medication was prescribed.
At the emergency Nonbiological_location department Nonbiological_location , she presented Clinical_event with drowsiness Sign_symptom and a body Diagnostic_procedure temperature Diagnostic_procedure of 37.0℃ Lab_value , blood Diagnostic_procedure pressure Diagnostic_procedure of 90/60 Lab_value mmHg Lab_value , heart Diagnostic_procedure rate Diagnostic_procedure of 200 Lab_value bpm Lab_value , respiratory Diagnostic_procedure rate Diagnostic_procedure of 32 Lab_value breaths/min Lab_value , oxygen Diagnostic_procedure saturation Diagnostic_procedure of 99% Lab_value in 5 Lab_value L Lab_value nasal Lab_value air Lab_value , and a Glasgow Diagnostic_procedure coma Diagnostic_procedure scale Diagnostic_procedure ( GCS Diagnostic_procedure ) score of 14 Lab_value .
Her clinical Diagnostic_procedure examination Diagnostic_procedure revealed a diffuse Detailed_description goiter Sign_symptom with bilateral Detailed_description exophthalmoses Detailed_description .
Her lungs Biological_structure were clear Lab_value when auscultated Diagnostic_procedure .
Her abdomen Biological_structure was soft Lab_value and non- tender Sign_symptom .
Her skin Biological_structure was warm Lab_value and wet Lab_value .
She had no lower Biological_structure extremity Biological_structure edema Sign_symptom .
The electrocardiogram Diagnostic_procedure showed marked Detailed_description tachycardia Sign_symptom with atrial Disease_disorder fibrillation Disease_disorder , and a chest Biological_structure radiograph Diagnostic_procedure was normal Lab_value .
The laboratory Diagnostic_procedure data Diagnostic_procedure are shown in Table 1.
Her initial laboratory Diagnostic_procedure data Diagnostic_procedure demonstrated marked metabolic Sign_symptom acidosis Sign_symptom , an increased Lab_value plasma Diagnostic_procedure glucose Diagnostic_procedure level of 472 Lab_value mg/dL Lab_value , an increased Lab_value HbA1c Diagnostic_procedure level of 13.7% Lab_value , an increased Lab_value free Diagnostic_procedure triiodothyronine Diagnostic_procedure level of 6.440 Lab_value pg/mL Lab_value , and a free Diagnostic_procedure thyroxine Diagnostic_procedure level of 2.830 Lab_value ng/dL Lab_value , with a suppressed Diagnostic_procedure thyrotropin Diagnostic_procedure (TSH) level of 0.005 Lab_value μIU/mL.
She scored 55 Lab_value on the diagnostic Diagnostic_procedure criteria Diagnostic_procedure of Diagnostic_procedure Burch Diagnostic_procedure & Diagnostic_procedure Wartofsky Diagnostic_procedure for Diagnostic_procedure thyroid Diagnostic_procedure storm Diagnostic_procedure , and the diagnostic Diagnostic_procedure criteria Diagnostic_procedure of Diagnostic_procedure the Diagnostic_procedure Japan Diagnostic_procedure Thyroid Diagnostic_procedure Association Diagnostic_procedure for Diagnostic_procedure thyroid Diagnostic_procedure storm Diagnostic_procedure were also satisfied Lab_value , since she had thyrotoxicosis Disease_disorder , symptoms Sign_symptom involving Sign_symptom the Sign_symptom central Sign_symptom nervous Sign_symptom system Sign_symptom , tachycardia Sign_symptom , and gastrointestinal Sign_symptom symptoms Sign_symptom (4).
Accordingly, she was diagnosed Clinical_event with DKA Disease_disorder and thyroid Disease_disorder storm Disease_disorder and admitted Clinical_event to the medical Nonbiological_location intensive Nonbiological_location care Nonbiological_location unit Nonbiological_location for further monitoring Diagnostic_procedure and treatment Therapeutic_procedure .
The clinical course is shown in Figure.
She was treated with an intravenous Administration insulin Medication drip Administration and aggressive Detailed_description intravenous Administration fluid Therapeutic_procedure therapy Therapeutic_procedure .
The thyroid Disease_disorder storm Disease_disorder with GD Disease_disorder was treated with intravenous Administration hydrocortisone Medication 100 Dosage mg Dosage every Dosage 8 Dosage hours Dosage , oral Administration potassium Medication iodine Medication 50 Dosage mg Dosage every Dosage 6 Dosage hours Dosage , and oral Administration methimazole Medication 20 Dosage mg Dosage every Dosage 6 Dosage hours Dosage .
Since she had a history of asthma History , landiolol Medication hydrochloride Medication , a short-acting beta-adrenoceptor blocker, was used at 4 Dosage - 12 Dosage μg/kg/min Dosage to control her heart rate.
By Day Date 3 Date , her tachycardia Sign_symptom had resolved, and landiolol Medication hydrochloride Medication was discontinued.
On Day Date 6 Date , the white Diagnostic_procedure blood Diagnostic_procedure cell Diagnostic_procedure count Diagnostic_procedure had decreased to 2,800 Lab_value cells/mm3 Lab_value [ neutrophils, Lab_value 44.2% Lab_value (1,238 Lab_value cells/mm3) Lab_value ].
Methimazole Medication was discontinued because methimazole Detailed_description - induced Detailed_description neutropenia Sign_symptom was suspected.
The patient was referred Clinical_event to an endocrine Nonbiological_location surgeon Nonbiological_location , and thyroidectomy Therapeutic_procedure was performed on Day Date 32 Date .
She was discharged Clinical_event from the hospital Nonbiological_location on Day Date 37 Date and maintained on multiple Dosage daily Dosage insulin Medication infusion Administration and levothyroxine Medication sodium Medication hydrate Medication .
Further immunological Diagnostic_procedure investigation Diagnostic_procedure revealed elevated Lab_value levels Lab_value of anti Diagnostic_procedure - glutamic Diagnostic_procedure acid Diagnostic_procedure decarboxylase Diagnostic_procedure (GAD) Diagnostic_procedure antibody Diagnostic_procedure , anti Diagnostic_procedure - insulinoma Diagnostic_procedure antigen Diagnostic_procedure 2 Diagnostic_procedure (IA-2) antibody Diagnostic_procedure , and insulin Diagnostic_procedure autoantibody Diagnostic_procedure , consistent with T1D.
The intravenous Diagnostic_procedure glucagon Diagnostic_procedure stimulation Diagnostic_procedure test Diagnostic_procedure was performed with blood Biological_structure samples Biological_structure for Detailed_description glucose Detailed_description and Detailed_description C Detailed_description - peptide Detailed_description taken Detailed_description at Detailed_description baseline Detailed_description and Detailed_description 6 Detailed_description minutes Detailed_description .
Her plasma Diagnostic_procedure glucose Diagnostic_procedure levels were 139 Lab_value and 152 Lab_value mg/dL Lab_value at baseline Detailed_description and 6 Detailed_description minutes Detailed_description , respectively.
The corresponding serum Diagnostic_procedure C Diagnostic_procedure - peptide Diagnostic_procedure levels were 0.8 Lab_value and 1.3 Lab_value ng/mL Lab_value at baseline Detailed_description and 6 Detailed_description minutes Detailed_description , respectively.