SUN-333 - First Reported Case of Non-Diabetic Ketoacidosis Secondary to Thyroid Storm: A Case Report

Background:  Ketoacidosis is a rare and serious metabolic abnormality most commonly associated with diabetes, starvation, alcohol use, and critical illness. Thyroid storm is a life-threatening emergency and represents an extreme state of thyrotoxicosis, often leading to multiorgan involvement and metabolic derangements. Though rare and uncommon, thyroid storm can also precipitate non-diabetic ketoacidosis.  
 

Case Presentation:  A 21 year old female patient with Grave’s disease, anxiety, and hypertension initially presented with acute onset of abdominal pain, nausea, diarrhea, and severe tachycardia for two days. She had been non-compliant with her anti-thyroid medication and was recently exposed to a sick contact with viral gastroenteritis. On arrival, she met criteria for thyroid storm with a calculated Burch Wartofsky Point Scale score of 50 points and thyroid hormone levels consistent with overt hyperthyroidism (TSH < 0.01 µIU/mL, free T4 4.69 ng/dL, free T3 22.42 pg/mL). Initial labs were notably significant for metabolic acidosis with a high anion gap (18 mEq/L), ketonuria (4+ ketones on urinalysis), and elevated beta-hydroxybutyrate (3.01 mmol/L) in the absence of diabetes mellitus, lactic acidosis, renal dysfunction, or alcohol use. These findings were consistent with non-diabetic ketoacidosis secondary to severe thyrotoxicosis. During her hospitalization, she was treated with hydrocortisone and methimazole initially then with propylthiouracil, propranolol, and Lugol’s iodine, resulting in clinical improvement. Noticeably, treatment of thyroid storm also led to improvement in the patient’s metabolic acidosis with anion gap decreasing from 18 mEq/L to 10 mEq/L by the end of her stay. On discharge, patient was given methimazole and propanolol along with instructions to follow up with an endocrinologist outpatient. 
 

Conclusion:  This case highlights a case of non-diabetic ketoacidosis as complication of Thyroid Storm. Though this has been reported in a case of thyrotoxicosis, our case may be the first reported case in a patient with Thyroid Storm. Prompt treatment of thyrotoxicosis with antithyroid medications and fluid resuscitation leads to clinical improvement and resolution of ketoacidosis.

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