Table 1 Laboratory data on admission (Case 1, S.K. 25 yrs. F.)

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1

2 Table 1 Laboratory data on admission (Case 1, S.K. 25 yrs. F.)

3 Fig. 1 Clinical course (Case 1, S.K. 25 yrs. F.) Table 2 Laboratory data on admission (Case 2, M.M. 37 yrs. F.)

4 Table 3 Plasma free amino acids level of the 2 nd case (37 yrs. F.) (micro mol/l.)

5 Fig. 2 Clinical course (Case 2, M. M. 37 yrs. F.)

6

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8 epinephrine and glucose and insulin on hepatic uptake of nonesterified fatty acids. Amer. J. Physiol. 199: (1960) 11) Bogdonoff, M. D., Estes, E. H., Jr., Friedberg, S. J., Klein, R. F.: Fat mobilization in man. Ann. Intern. Med. 55: (1961) 12) Elrick, H., Hlad, C. J., Jr., Arai, Y.: Influence insulin. J. Clin. Endocr. 21: (1961) 13) Hales, C. N., Hyams, D. E.: Plasma concentra- tions of glucose, non-esterified fatty acid, and insulin during oral glucose-tolerance tests in thyrotoxicosis. Lancet 2: (1964) 1) Irvine, W. J.: Classification of idiopathic diabetes. Lancet 1: (1977) 2) Christy, M., Deckert, T., Nerup, J.: Immunity and autoimmunity in diabetes mellitus. Clinics in Endocrinology and Metabolism 6 (2): (1977) 18) Jacobson, R., Horenstein, M., Kassel, L.: Hyperglycemia and hyperosmolarity in a brittle diabetic with thyrotoxicosis. Diabetes 19: (1970) 19) Houssay, B. A.: Thyroid and metathyroid diabetes. 7) Perlman, L. V.: Familial incidence of diabetes Endocrinology 35: (1944) in hyperthyroidism. Ann. Intern. Med. 55: 20) Bottazzo, G. F., Doniach, D.: Pancreatic autoimmunity (1961) and HLA antigens. Lancet 2: 800 8) Landing, B. H., Pettit, M. D., Wiens, R. L., Knowles, H., Guest, G. M.: Antithyroid anti- body and chronic thyroiditis in diabetes. J. Clin. Endocr. 23: (1963) 9) Kozak, G. P.: Diabetes and other endocrinologic disorders. "Joslin's Diabetes Mellitus" Marble, A., White, P., Bradley, R. F., Krall, L.P. 11 th ed. Lea & Febiger Co., Philadelphia. (1971) p ) Fine, M. B., Williams, R. H.: Effect of fasting, of thyroid function on carbohydrate metabolism and a new method for assessing response to (1976) 21) Irvine, W. J., McCallum, C. J., Gray, R. S., Cambell, C. J., Duncan, L. J. P., Farquhar, J. W., Vaughan, H., Morris, P. J.: Pancreatic islet-cell antibodies in diabetes mellitus correlated with the duration and type of diabetes, coexistent autoimmune disease, and HLA type. Diabetes 26: (1977) 22) Berger, M., Zimmermann-Telschow, H., Berchtold, P., Drost, H., Muller, W. A., Gries,

9 F. A., Zimmermann, H.: Blood amino acid levels in patients with insulin excess (functioning insulinoma) and insulin deficiency (diabetic ketosis). Metabolism 27: (1978) 23) Pittman, C. S., Suda, A. K., Chambers, J. B., Jr., Ray, G. Y.: Impaired 3, 5, 3'-triiodothyronine (T3) production in diabetic patients. Metabolism 28: (1979) 24) Naeije, R., Goldstein, J. Clumeck, N., Meinhold, H., Wenzel, K.W., Vanhaelst,L.: A low T3 syndrome in diabetic ketoacidosis. Clin. Endocrinol. 8: (1978)

10 Abstract Two Cases of Hyperthyroidism Complicated with Diabetic Ketoacidotic Coma Umeo Miwa, Shunichi Sakato, Kohei Yoshimitsu, Takashi Sato, Kiyoo Mori, Yuichi Haseda, Kimiaki Yoshino, Hideki Yamamoto, Tamehisa Onoe, Takio Ohka and Yasaka Kinoshita Department of Internal Medicine, Ishikawa Prefectural Central Hospital, Kanazawa The incidence of overt diabetes in patients with hyperthyroidism has been reported to be 2 to 3 %. Only a few cases of coexisting diabetic ketoacidosis and clinical hyperthyroidism have been reported in Japan. We describe two young female patients who developed diabetic ketoacidotic precoma after longterm preexisting hyperthyroidism. Case 1: The patient, a 25-year-old female, developed hyperthyroidism at the age of 18 yrs, but had been incompletely treated. She was admitted to our clinic complaining of sudden onset of thirst, general malaise and somnolence. Physical examination on admission revealed a dehydrated lady in somnolence with struma (grade 2), dry skin and mucous membrane. The laboratory data were : urinary glucose and ketone bodies, strongly positive; blood glucose, 636 mg/dl; arterial ph, 7.236; PCO mmhg; base excess (BE) -17 meq/l ; HCO3-8.5 meq/l ; Ht 48%; T3RU 51.5%; T Đg/dl ; T3 270 ng/dl ; TSH below 1 Đu/ml ; thyroid and microsome tests, both positive. Case 2: The patient, a 37-year-old female, developed hyperthyroidism at the age of 23 yrs, but had received only occasional therapy as in Case 1. She was transferred to our clinic because of vomiting, palpitations and somnolence. Physical examination on admission revealed somnolence (severe), sinus tachycardia (154/min), dry skin and mucous membrane. Goiter was not found. The laboratory data were; urinary glucose and ketone bodies, strongly positive; blood glucose, above 400 mg/dl; arterial ph, 7.176; PCO mmhg; BE meq/l; HCO3-6.4 meq/l ; Ht 53%; T3RU 51.8%; T Đg/dl: T3 280 ng/dl ; TSH below 1 Đu/ml; microsome test, positive. Both patients recovered quickly from their impaired consciousness following intravenous administration of saline solution combined with insulin preparation. However, the daily insulin requirement had increased since the serum level of thyroid hormones was elevated during the hospital course until an antithyroid drug was administered. Antithyroid drug therapy resulted in a decrease of the insulin requirement, indicating that the hyperthyroid state had affected the glucose tolerance and actually precipitated diabetic ketoacidosis in these cases. The present two cases appear to represent a clinical example of the 'metathyroid diabetes' proposed by Dr. Houssay. However, according to current concepts of autoimmunity, the possible mechanism common to the coexistence of insulin dependent diabetes and clinical hyperthyroidism may be involved in these cases. J. Japan Diab. Soc. 23(9) : , 1980

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