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Severe hypoglycemia accompanied with thyroid crisis.
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PMID:  23198181     Owner:  NLM     Status:  PubMed-not-MEDLINE    
We report a 32-year-old Japanese women with severe hypoglycemia accompanied with thyroid crisis. She complained of dyspnea, general fatigue, and leg edema. She was diagnosed with hyperthyroidism with congestive heart failure and liver dysfunction. Soon after admission, sudden cardiopulmonary arrest occurred. She was then transferred to the intensive care unit. Her serum glucose level was 7 mg/dl. Intravenous glucose, hydrocortisone, diuretics, and continuous hemodiafiltration (CHDF) saved her. We considered that hypoglycemia occurred due to heart failure and liver dysfunction due to thyroid crisis.
Yuki Nakatani; Tsuyoshi Monden; Minoru Sato; Nozomi Domeki; Mihoko Matsumura; Nobuyuki Banba; Takaaki Nakamoto
Publication Detail:
Type:  Journal Article     Date:  2012-11-04
Journal Detail:
Title:  Case reports in endocrinology     Volume:  2012     ISSN:  2090-651X     ISO Abbreviation:  Case Rep Endocrinol     Publication Date:  2012  
Date Detail:
Created Date:  2012-11-30     Completed Date:  2012-12-03     Revised Date:  2013-04-18    
Medline Journal Info:
Nlm Unique ID:  101576457     Medline TA:  Case Rep Endocrinol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  168565     Citation Subset:  -    
Department of Endocrinology and Metabolism, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan ; Department of Diabetes & Endocrinology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko-shi, Tochigi 321-2593, Japan.
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Journal Information
Journal ID (nlm-ta): Case Report Endocrinol
Journal ID (iso-abbrev): Case Report Endocrinol
Journal ID (publisher-id): CRIM.ENDOCRINOLOGY
ISSN: 2090-6501
ISSN: 2090-651X
Publisher: Hindawi Publishing Corporation
Article Information
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Copyright © 2012 Yuki Nakatani et al.
Received Day: 10 Month: 9 Year: 2012
Accepted Day: 9 Month: 10 Year: 2012
Print publication date: Year: 2012
Electronic publication date: Day: 4 Month: 11 Year: 2012
Volume: 2012E-location ID: 168565
PubMed Id: 23198181
ID: 3502800
DOI: 10.1155/2012/168565

Severe Hypoglycemia Accompanied with Thyroid Crisis
Yuki Nakatani12*
Tsuyoshi Monden3
Minoru Sato1
Nozomi Domeki1
Mihoko Matsumura1
Nobuyuki Banba2
Takaaki Nakamoto4
1Department of Endocrinology and Metabolism, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan
2Department of Diabetes & Endocrinology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko-shi, Tochigi 321-2593, Japan
3Monden Clinic, 115 Tenjincho, Takasaki-shi, Gunma 370-0061, Japan
4Department of Cardiology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko-shi, Tochigi 321-2593, Japan
Correspondence: *Yuki Nakatani:
[other] Academic Editors: H. Hattori, T. Nagase, and A. Sahdev

1. Introduction

Hypoglycemia occurs with diabetes treatment, anorexia nervosa, liver disease, and adrenal insufficiency. Hyperthyroidism usually induces impaired glucose tolerance. However, hyperthyroidism with congestive heart failure or liver dysfunction is considered to induce hypoglycemia, but this is very rare. We describe here a case of thyroid crisis accompanied with severe hypoglycemia. Although the patient's heart arrested, combined and intensive treatment saved her.

2. Case Report

A 32-year-old Japanese woman was admitted to our hospital in January because of dyspnea, general fatigue, and legs edema. She had been well until one month earlier and had not been diagnosed with hyperthyroidism. There was no family history of thyroid disease.

On admission, she was 157 cm tall and weighed 68.4 kg. Her body temperature was 36.9°C, blood pressure was 120/80 mmHg, and pulse rate was 132/min with irregularities. She was alert and oriented (Glasgow Coma Scale 15/15). Exophthalmos was not observed, but a diffuse enlarged thyroid was detected. Conjunctiva was not anemic, but was slightly icteric. Marked edema was found in both legs. Cardiac symptoms were recognized as class four of the New York Heart Association classification.

Laboratory data indicated hyperthyroidism (free T3: >30.0 pg/mL, free T4: >6.0 ng/dL). The anti-TSH receptor antibody was elevated to 23.6 IU/L (Table 1). Electrocardiogram showed atrial fibrillation and chest X-ray showed cardiomegaly (CTR = 65.2%) and effusion. Based on these findings, the patient was diagnosed with Graves' disease complicated with severe cardiac failure. Her condition was recognized as thyroid crisis, as described by Burch and Wartofsky [1] and the Japanese Thyroid Association [2]. She was started on thiamazole, propranolol, and furosemide. In addition, we did not use steroid and iodine. Because her consciousness was clear,we thought her thyroid crisis was not severe. Her glucose level was relatively low (57 mg/dL) before meals, and she ate food at dinner time. On the first night in the hospital, she suddenly lost consciousness and suffered cardiopulmonary arrest. Immediate cardiopulmonary rescue recovered her condition. She was then transferred to the intensive care unit. Hypoglycemia (7 mg/dL), severe right-side heart failure, and liver dysfunction by liver congestion were revealed. As her condition was multiple organ failure caused by thyroid crisis, intravenous glucose, hydrocortisone, methimazole, and diuretics were administered. To maintain circulation status, continuous hemodiafiltration was performed for 7 days. As her condition improved and laboratory data reached normal ranges, she was discharged after 74 days in the hospital.

3. Discussion

This case was determined as a definite case of thyroid storm by the criteria for thyroid storm described by Burch and Wartofsky (score, 85/140) [1]. In addition, the Japanese Thyroid Association has recently established the diagnostic criteria for thyroid crisis [2]. By these criteria, thyroid crisis has been diagnosed on the basis of the following five symptoms: (1) central nervous system manifestations; (2) fever (38°C or higher); (3) tachycardia (130 beats/min or faster); (4) congestive heart failure; (5) gastrointestinal manifestations. Definite cases are diagnosed by the following criteria: (1) central nervous system manifestations, plus one or more other symptoms, or (2) three or more of the manifestations other than central nervous system manifestations. On the basis of the criteria, this patient was diagnosed as a definitive case of thyroid crisis (increased serum thyroxine, central nerve symptoms (coma), tachycardia (132 beats/min), congestive heart failure, and liver dysfunction with icterus).

This case was very rare because of hypoglycemia. In the English literature, there were three case reports of hypoglycemia accompanied by hyperthyroidism. The first case was caused by anorexia [3], the second was caused by liver dysfunction and lactic acidosis [4], and the cause of the third was not clear [5]. In the present case, insulin autoimmune syndrome was not observed because of the low level of immune reactive insulin (2.0 μU/mL) and anti-insulin antibody is negative.Anorexia nervosa was rejected because of her past history and symptoms. Moreover, adrenal insufficiency was negative (ACTH: 61.3 pg/mL, cortisol: 17.3 mg/mL). Our case showed severe congestive heart failure (EF = 53.8%, IVC = 25.9 mm, respiratory changes did not occur) and liver dysfunction with icterus. Therefore, we believe that hypoglycemia may have been caused by congestive heart failure and liver dysfunction. Although lactic acid was not determined, our case resembled the second case reported by Kobayashi et al. [4]. Congestive heart failure is associated with hypoglycemia because of decreasing insulin clearance and severe liver dysfunction, which inhibits glucose release from liver cells [6].

This case presented here is of clinical importance. Serum glucose levels should be checked in patients with thyroid crisis, especially when accompanied with heart failure and liver dysfunction. We should pay attention to glucose levels in the course of hyperthyroidism in cases like this. Fortunately, this patient was saved from thyroid crisis by intensive care including CHDF. However, we should remember hypoglycemia as a cause of loss of consciousness to avoid delayed diagnosis or management of thyroid crisis.

1. Burch HB,Wartofsky L. Life-threatening thyrotoxicosis: thyroid stormEndocrinology and Metabolism Clinics of North AmericaYear: 19932222632772-s2.0-00272311458325286
2. Akamizu T,Satoh T,Isozaki O,et al. Diagnostic criteria and clinic-epideminological features of thyroid strom based on a nationwide surveyThyroidYear: 201222766167922690898
3. Izumi K,Kondo S,Okada T. A case of atypical thyroid storm with hypoglycemia and lactic acidosisEndocrine JournalYear: 20095667477522-s2.0-7034993961119506329
4. Kobayashi C,Sasaki H,Kosuge K,et al. Severe starvation hypoglycemia and congestive heart failure induced by thyroid crisis, with accidentally induced severe liver dysfunction and disseminated intravascular coagulationInternal MedicineYear: 20054432342392-s2.0-1774438794015805713
5. Homma M,Shimizu S,Ogata M,Yamada Y,Saito T,Yamamoto T. Hypoglycemic coma masquerading thyrotoxic stormInternal MedicineYear: 199938118718742-s2.0-003322697310563748
6. Service FJ. Hypoglycemic disordersThe New England Journal of MedicineYear: 199533217114411522-s2.0-00289410737700289

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