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Diagnosis and Treatment > Signs and Symptoms

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Yuri Tanaka Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Taisuke Uchida Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Hideki Yamaguchi Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Yohei Kudo Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Tadato Yonekawa Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Masamitsu Nakazato Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Summary

We report the case of a 48-year-old man with thyroid storm associated with fulminant hepatitis and elevated levels of soluble interleukin-2 receptor (sIL-2R). Fatigue, low-grade fever, shortness of breath, and weight loss developed over several months. The patient was admitted to the hospital because of tachycardia-induced heart failure and liver dysfunction. Graves’ disease with heart failure was diagnosed. He was treated with methimazole, inorganic iodide, and a β-blocker. On the day after admission, he became unconscious with a high fever and was transferred to the intensive care unit. Cardiogenic shock with atrial flutter was treated with intra-aortic balloon pumping and cardioversion. Hyperthyroidism decreased over 10 days, but hepatic failure developed. He was diagnosed with thyroid storm accompanied by fulminant hepatitis. Laboratory investigations revealed elevated levels of sIL-2R (9770 U/mL). The fulminant hepatitis was refractory to plasma exchange and plasma filtration with dialysis, and no donors for liver transplantation were available. He died of hemoperitoneum and gastrointestinal hemorrhage due to fulminant hepatitis 62 days after admission. Elevated circulating levels of sIL-2R might be a marker of poor prognosis in thyroid storm with fulminant hepatitis.

Learning points:

  • The prognosis of thyroid storm when fulminant hepatitis occurs is poor.

  • Liver transplantation is the preferred treatment for fulminant hepatitis induced by thyroid storm refractory to plasma exchange.

  • Elevated levels of soluble interleukin-2 receptor might be a marker of poor prognosis in patients with thyroid storm.

Taxonomy:
Clinical Overview, Gland/Organ, Heart, Liver, Thyroid, Hormone, Thyroxine (T4), Triiodothyronine (T3), TSH, Condition/ Syndrome, Graves' disease, Liver failure, Thyroid storm, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Japan, Diagnosis and Treatment, Signs and Symptoms, Atrial fibrillation, Breathing difficulties, Cardiogenic shock, Cardiomegaly, Coagulopathy, Dyspnoea, Fatigue, Goitre, Heart failure, Hyperhidrosis, Hyperthyroidism, Hypoglycaemia, Hypoxia, Jaundice, Metabolic acidosis, Oedema, Pyrexia, Renal failure, Tachycardia, Weight loss, Investigation, Alanine aminotransferase, Albumin, Alkaline phosphatase, Ammonia, Bilirubin, Brain natriuretic peptide, Calcium (serum), C-reactive protein, Creatinine, CT scan, Echocardiogram, FT3, FT4, Glucose (blood), Lactate dehydrogenase, Potassium, Thyroid antibodies, Transaminase, TSH, X-ray, Intervention, Dialysis, Plasma exchange, Medication, Beta-blockers, Glucocorticoids, Glucose, Hydrocortisone, Methimazole, Potassium iodide, Propylthiouracil, Related Disciplines, Cardiology, Gastroenterology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-19-0078
Volume/Issue:
Volume 2019: Issue 1
Open access
Hodaka Yamada Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan

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Shunsuke Funazaki Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan

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Masafumi Kakei Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan

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Kazuo Hara Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan

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San-e Ishikawa Division of Endocrinology and Metabolism, International University of Health and Welfare Hospital, Nasushiobara, Japan

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Summary

Diabetic ketoacidosis (DKA) is a critical complication of type 1 diabetes associated with water and electrolyte disorders. Here, we report a case of DKA with extreme hyperkalemia (9.0 mEq/L) in a patient with type 1 diabetes on hemodialysis. He had a left frontal cerebral infarction resulting in inability to manage his continuous subcutaneous insulin infusion pump. Electrocardiography showed typical changes of hyperkalemia, including absent P waves, prolonged QRS interval and tented T waves. There was no evidence of total body water deficit. After starting insulin and rapid hemodialysis, the serum potassium level was normalized. Although DKA may present with hypokalemia, rapid hemodialysis may be necessary to resolve severe hyperkalemia in a patient with renal failure.

Learning points:

  • Patients with type 1 diabetes on hemodialysis may develop ketoacidosis because of discontinuation of insulin treatment.

  • Patients on hemodialysis who develop ketoacidosis may have hyperkalemia because of anuria.

  • Absolute insulin deficit alters potassium distribution between the intracellular and extracellular space, and anuria abolishes urinary excretion of potassium.

  • Rapid hemodialysis along with intensive insulin therapy can improve hyperkalemia, while fluid infusions may worsen heart failure in patients with ketoacidosis who routinely require hemodialysis.

Taxonomy:
Clinical Overview, Gland/Organ, Kidney, Topic, Diabetes, Hormone, Insulin, Condition/ Syndrome, Diabetes mellitus type 1, Diabetic ketoacidosis, Diabetic nephropathy, Hyperglycaemia, Hyperkalaemia, Hyponatraemia, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Germany, Diagnosis and Treatment, Signs and Symptoms, Acalculia, Anuria, Cardiomegaly, Diabetes mellitus type 1, Diabetic ketoacidosis, Hemiparesis, Hyperglycaemia, Hyperkalaemia, Hyponatraemia, Oedema, Weight gain, Investigation, Acid-base balance, Bicarbonate, CT scan, Electrocardiogram, Glucose (blood), pH (blood), Potassium, Sodium, X-ray, Intervention, Dialysis, Medication, Insulin, Publication Details, Case Report Type, Insight into disease pathogenesis or mechanism of therapy
DOI:
https://doi.org/10.1530/EDM-17-0068
Volume/Issue:
Volume 2017: Issue 1
Open access