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Thyroid Biology and Disease

MON-384 - A Perfect Storm: Severe DKA and Hashimoto'S Encephalopathy in A Young Adult

Monday, June 15, 2026
9:00 AM - 2:00 PM CT
Location: ENDOExpo; Poster Floor
Introduction
Severe endocrine and metabolic emergencies can present simultaneously and pose diagnostic and therapeutic challenges. Diabetic ketoacidosis (DKA) and Hashimoto’s encephalopathy are rare but potentially life-threatening conditions that may manifest with altered mental status, particularly in patients with medication nonadherence and self-neglect. Early recognition and multidisciplinary management are essential to prevent irreversible complications.
Case Description
A 29-year-old woman with a history of hypothyroidism and medication nonadherence was found at home in unsafe and unsanitary conditions with altered mental status and Kussmaul respirations. Initial evaluation revealed profound metabolic acidosis (arterial pH 6.77), severe hyperglycemia (648 mg/dL), marked leukocytosis (41.8 K/µL), markedly elevated thyroid-stimulating hormone (57.2 mIU/mL), and low free thyroxine (0.22 ng/dL). She required emergent intubation for impending respiratory failure and was admitted to the intensive care unit. The working diagnoses included mixed DKA and hyperosmolar hyperglycemic state, severe hypothyroidism with suspected Hashimoto’s encephalopathy, gram-negative bacteremia, and major depressive disorder contributing to severe self-neglect.
Management included aggressive intravenous fluid resuscitation, continuous insulin infusion with transition to subcutaneous insulin, intravenous levothyroxine, stress-dose corticosteroids, and broad-spectrum antibiotics. Psychiatry and social services were consulted early to address underlying depression, unsafe living conditions, and barriers to medication adherence.
Results/Outcome
Metabolic abnormalities gradually resolved with treatment. Neurological status improved in parallel with correction of acidosis and stabilization of thyroid function. Blood cultures cleared with targeted antimicrobial therapy. The patient was successfully extubated and discharged on an optimized endocrine regimen with coordinated outpatient follow-up.
Conclusion
This case highlights the importance of considering concurrent endocrine emergencies in patients presenting with altered mental status. Severe hypothyroidism may exacerbate metabolic instability and contribute to encephalopathy in the setting of DKA. Early multidisciplinary collaboration is critical for acute stabilization, recovery, and prevention of recurrence through long-term endocrine and psychiatric care.

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