# Convergence of Crisis: A Case Report of Diabetic Ketoacidosis Masking an Impending Thyroid Storm and Periodic Paralysis

## TL;DR

A patient with diabetes and hyperthyroidism developed a life-threatening combination of diabetic ketoacidosis, thyroid storm, and periodic paralysis, requiring urgent and coordinated treatment.

## Contribution

This case report highlights the rare and complex interplay of three metabolic emergencies in a single patient.

## Key findings

- A 41-year-old female with type 1 diabetes and hyperthyroidism presented with DKA, impending thyroid storm, and hypokalemia-induced paralysis.
- Aggressive treatment with fluids, insulin, anti-thyroid drugs, and potassium supplementation led to stabilization.
- The case underscores the need for comprehensive management in patients with multiple metabolic comorbidities.

## Abstract

Diabetic ketoacidosis (DKA) is an extreme complication of diabetes mellitus characterized by hyperglycemia, metabolic acidosis, and ketonemia. Thyroid storm, a potentially life-threatening manifestation of thyrotoxicosis, presents with a multitude of symptoms, including hyperthermia, tachycardia, and altered mental status. Periodic paralysis can be precipitated by different metabolic disturbances, including thyrotoxicosis, and may lead to extreme episodes of muscle weakness and paralysis. We present a case of a 41-year-old female with a history of type 1 diabetes mellitus and hyperthyroidism, who presented with DKA complicated by an impending thyroid storm and likely periodic paralysis exacerbated due to hypokalemia. Prompt recognition and aggressive management of each component of this triad were essential for a positive patient outcome.

This case highlights the importance of a broad and comprehensive approach to managing complex metabolic emergencies, particularly in patients with multiple comorbidities. Our patient presented to the emergency department with symptoms of severe vomiting, shortness of breath, and altered mental status. Laboratory investigations revealed metabolic derangements consistent with DKA, alongside impending thyrotoxicosis and hypokalemia-induced periodic paralysis. Management involved aggressive fluid resuscitation, insulin therapy, anti-thyroid medications, and potassium supplementation, with a multidisciplinary approach to stabilize the patient's condition.