A 32-year-old woman with a 13-year history of type 1 diabetes mellitus comes to the hospital with palpitations and shortness of breath. She has had these symptoms for the last several months, but they have worsened recently. The patient also has experienced anxiety, poor sleep, and unintentional weight loss that she attributes to drinking too much coffee at work. She drinks 2 8-oz cups of coffee daily and a glass of red wine on weekends. The patient's diabetes is managed with a regimen of insulin glargine and insulin lispro, and she has had good glycemic control in the past. However, in the last few months she has had rising home glucose readings and has required increasing insulin doses to maintain control. The patient has also had irregular menstrual periods, for which she was started on a combination estrogen-progesterone oral contraceptive pill 2 months ago. CT scan of the chest with contrast performed in the emergency department shows no evidence of pulmonary embolism, and the patient is admitted for additional evaluation. Following admission, she develops nausea and vomiting. Six hours later, the patient is found to be confused, diaphoretic, and agitated. Her temperature is 38.9 C (102 F), blood pressure is 145/65 mm Hg, and pulse is 154/min. The chest is clear to auscultation. Examination of skin and abdomen is unremarkable. Laboratory results are as follows: Which of the following is the most likely diagnosis?

Question

A 32-year-old woman with a 13-year history of type 1 diabetes mellitus comes to the hospital with palpitations and shortness of breath.  She has had these symptoms for the last several months, but they have worsened recently.  The patient also has experienced anxiety, poor sleep, and unintentional weight loss that she attributes to drinking too much coffee at work.  She drinks 2 8-oz cups of coffee daily and a glass of red wine on weekends.  The patient's diabetes is managed with a regimen of insulin glargine and insulin lispro, and she has had good glycemic control in the past.  However, in the last few months she has had rising home glucose readings and has required increasing insulin doses to maintain control.  The patient has also had irregular menstrual periods, for which she was started on a combination estrogen-progesterone oral contraceptive pill 2 months ago.  CT scan of the chest with contrast performed in the emergency department shows no evidence of pulmonary embolism, and the patient is admitted for additional evaluation.  Following admission, she develops nausea and vomiting.  Six hours later, the patient is found to be confused, diaphoretic, and agitated.  Her temperature is 38.9 C (102 F), blood pressure is 145/65 mm Hg, and pulse is 154/min.  The chest is clear to auscultation.  Examination of skin and abdomen is unremarkable.  Laboratory results are as follows:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d3be_65e3_bc81_5500cbf9eb6a_MD0003_00 This patient initially presented with clinical features suggestive of hyperthyroidism, including palpitations, weight loss, irregular menses, and impaired glycemic control. A few hours following her initial evaluation and hospitalization, she developed pyrexia, tachycardia, delirium, and vomiting, concerning for thyroid storm (severe or life-threatening thyrotoxicosis) likely triggered by acute iodine load from undergoing a CT scan with iodinated contrast agent. Thyroid storm can also be triggered by surgery, trauma, infection, or childbirth. Proposed mechanisms include a rapid increase in blood thyroid hormone levels, increased cellular response to thyroid hormones, and an exaggerated response to catecholamines. Thyroid storm can lead to cardiac arrhythmias, congestive heart failure, seizures, hypotension, and shock. The diagnosis is based on clinical evaluation. Thyroid storm is usually seen in patients with undiagnosed or inadequately treated hyperthyroidism, as in this patient who is at risk for autoimmune thyroid disease (eg, Graves disease) in light of her type 1 diabetes. (Choice A) Delayed hypersensitivity to iodine contrast occurs 1 hour to several days after exposure and causes a rash that resolves spontaneously without significant hemodynamic effects. Immediate hypersensitivity can cause hemodynamic instability (along with urticaria and angioedema) but usually occurs within an hour of exposure. (Choice B) Although this patient has hyperglycemia, her serum bicarbonate and anion gap are normal, which is not consistent with diabetic ketoacidosis. Unlike this patient, most individuals with diabetic ketoacidosis are dehydrated and many are hypotensive. (Choice C) Acute hepatic injury is a common manifestation of thyroid storm. Hepatic encephalopathy, however, most often occurs in patients with stigmata of chronic liver disease (eg, palmar erythema, spider angioma, ascites), often with hypoalbuminemia and hyponatremia. (Choice D) Subsegmental pulmonary emboli are usually hemodynamically insignificant and cause pleuritic chest pain, dyspnea, tachypnea, and tachycardia. Massive pulmonary embolism may cause significant hypotension but is usually visible on CT scan. Educational objective: Thyroid storm is a life-threatening thyrotoxicosis usually triggered by a specific event (eg, surgery, trauma, infection, iodine contrast, childbirth) in patients with undiagnosed or inadequately treated hyperthyroidism. Patients can develop fever, hemodynamic instability, cardiac arrhythmias, and congestive heart failure. References: In the eye of the storm: iodinated contrast medium induced thyroid storm presenting as cardiopulmonary arrest. (http://www.ncbi.nlm.nih.gov/pubmed/23711892)

A 32-Year-Old Woman with a 13-Year History of Type 1