Thyrotoxic crisis in a patient with coexisting Graves’ disease and type 1 diabetes mellitus

Thyrotoxic crisis (TC) is a rare but potentially life-threatening complication of decompensated thyrotoxicosis that requires immediate medical intervention. The diagnosis of TC is based on a clinical picture of severe hyperthyroidism in combination with precipitating factors. Treatment should be initiated at the first suspicion of crisis development, without waiting for the results of hormonal analysis, which may take considerable time to obtain. This article presents a clinical case of a female patient with coexisting Graves’ disease and type 1 diabetes mellitus, in whom TC was promptly recognized and effectively managed. The precipitating factor was diabetic ketoacidosis. This case highlights the importance of early diagnosis and intensive therapy to improve the prognosis of patients with TC.

1. Ross DS, Burch HB, Cooper DS, et al. American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26(10):1343–1421. doi: https://doi.org/10.1089/thy.2016.0229

2. Galindo RJ, Hurtado CR, Pasquel FJ, et al. National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004–2013. Thyroid. 2019;29(1):36–43. doi: https://doi.org/10.1089/thy.2018.0275

3. Wang HI, Yiang GT, Hsu CW, et al. Thyroid Storm in a Patient with Trauma - A Challenging Diagnosis for the Emergency Physician: Case Report and Literature Review. J Emerg Med. 2017;52(3):292–298. doi: https://doi.org/10.1016/j.jemermed.2016.09.003

4. de Mul N, Damstra J, Nieveen van Dijkum EJM, et al. Risk of perioperative thyroid storm in hyperthyroid patients: a systematic review. Br J Anaesth. 2021;127(6):879-889. doi: https://doi.org/10.1016/j.bja.2021.06.043

5. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993;22(2):263-277

6. Mkrtumyan A.M. Emergency endocrinology: textbook / A.M. Mkrtumyan, A.A. Nelaeva. – 3rd ed., rev. – Moscow: GEOTAR-Media, 2022. – 128 p. (In Russ.)

7. Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. 2012;22(7):661–679. doi: https://doi.org/10.1089/thy.2011.0334

8. de Almeida R, McCalmon S, Cabandugama PK. Clinical Review and Update on the Management of Thyroid Storm. Mo Med. 2022;119(4):366–371

9. Satoh T, Isozaki O, Suzuki A, et al. Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J. 2016;63(12):1025-1064. doi: https://doi.org/10.1507/endocrj.EJ16-0336

10. Michels AW, Brusko TM, Evans-Molina C, Homann D, Richardson SJ, Powers AC. Challenges and Opportunities for Understanding the Pathogenesis of Type 1 Diabetes: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab. 2025;110(9):2496-2508. doi: https://doi.org/10.1210/clinem/dgaf267

11. Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia. 2024;67(8):1455-1479. doi: https://doi.org/10.1007/s00125-024-06183-8

12. Russian Association of Endocrinologists. Clinical guidelines for the diagnosis and treatment of thyrotoxicosis with diffuse goiter (Graves’ disease), nodular/multinodular goiter [Electronic resource]. Moscow, 2025. URL: https://rae-org.ru/system/files/documents/pdf/cr_thyro_greyw_2025.pdf (Date of access: 08.10.2025). (In Russ.)

13. Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. J Intensive Care Med. 2015;30(3):131-140. doi: https://doi.org/10.1177/0885066613498053

14. Eng PH, Cardona GR, Fang SL, et al. Escape from the acute Wolff-Chaikoff effect is associated with a decrease in thyroid sodium/iodide symporter messenger ribonucleic acid and protein. Endocrinology. 1999;140(8):3404-3410. doi: https://doi.org/10.1210/endo.140.8.6893

15. Southern AP, Anastasopoulou C, Jwayyed S. Iodine Toxicity. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 2, 2024

16. Takizawa H, Uchida T, Suzuki N, et al. Influence of therapeutic inorganic iodine on long-term prognosis of Graves’ disease: a multicenter prospective observational study. Endocr J. 2025;72(6):663-670. doi: https://doi.org/10.1507/endocrj.EJ24-0575

17. Ma Y, Li H, Liu J, Lin X, Liu H. Impending thyroid storm in a pregnant woman with undiagnosed hyperthyroidism: A case report and literature review. Medicine (Baltimore). 2018;97(3):e9606. doi: https://doi.org/10.1097/MD.0000000000009606

18. Alfadhli E, Gianoukakis AG. Management of severe thyrotoxicosis when the gastrointestinal tract is compromised. Thyroid. 2011;21(3):215-220. doi: https://doi.org/10.1089/thy.2010.0159

19. Lee SY, Rhee CM, Leung AM, Braverman LE, Brent GA, Pearce EN. A review: Radiographic iodinated contrast media-induced thyroid dysfunction. J Clin Endocrinol Metab. 2015;100(2):376-383. doi: https://doi.org/10.1210/jc.2014-3292

20. Sato S, Noh JY, Sato S, et al. Comparison of efficacy and adverse effects between methimazole 15 mg+inorganic iodine 38 mg/day and methimazole 30 mg/day as initial therapy for Graves’ disease patients with moderate to severe hyperthyroidism. Thyroid. 2015;25(1):43-50. doi: https://doi.org/10.1089/thy.2014.0084

21. Takata K, Amino N, Kubota S, et al. Benefit of short-term iodide supplementation to antithyroid drug treatment of thyrotoxicosis due to Graves’ disease. Clin Endocrinol (Oxf ). 2010;72(6):845-850. doi: https://doi.org/10.1111/j.1365-2265.2009.03745.x

22. Keklik M, Kaynar L, Yilmaz M, et al. The results of therapeutic plasma exchange in patients with severe hyperthyroidism: a retrospective multicenter study. Transfus Apher Sci. 2013;48(3):327-330. doi: https://doi.org/10.1016/j.transci.2013.04.010