37 yo female, 8 months postpartum, with no significant PMH presenting with swollen right sided neck mass x2 days. She reports having generalized body aches, persistent cough, runny nose, neck stiffness and Tmax of 102. She now also reports dysphagia and odynophagia. She was seen by her PMD 2 days ago and stated on Keflex.
THE CASE…
PHYSICAL EXAM…
Vital Signs:BP 123/66, pulse 113, temperature 101 degrees F, resp. rate 16,
HEENT: R sided neck tenderness and fullness. No stridor. No difficulty managing secretions.
CV: tachycardia, regular rhythm, no MRG
Lungs: clear lung sounds No wheezing
GI: soft, nondistended, normal bowel sounds
Skin: no rash, clammy
WORK UP…
CBC- WBC 11, HGB 11 HCT 32.3 Plt 200
Chemistry- Na 140 K 3.9 Cl 104 CO2 28 Cr. 1.0 BUN 19 Glu 88
TSH <0.008
T3 9.6
T4 3.48
Cultures pending
CT neck: negative for abscess or lymphadenitis, revealed enlarged right thyroid lobe with areas of decreased attenuation
CXR- hazy opacity in right lower lobe
EKG- sinus tachycardia
DIFFERENTIAL DIAGNOSES
pheochromocytoma
infection
sepsis
neuroleptic malignant syndrome
Hyperthermia
thyrotoxicosis/thyroiditis
thyroid storm
THYROID STORMAcute, severe, life
threatening state of thyrotoxicosis caused by adrenergic hyperactivity or altered peripheral response to thyroid hormone due to one or more precipitants
Clinical diagnosis for patients with existing hyperthyroidism
THYROID STORM PRECIPITANTS:
INFECTION
TRAUMA
SURGERY
STRESS
DKA/HYPOGLYCEMIA
WITHDRAWAL OF ANTITHYROID MEDICATION
IODINE ADMINISTRATION
MYOCARDIAL INFARCTION
PULMONARY EMBOLISM
ECLAMPSIA
VIGOROUS MANIPULATION OF THYROID GLAND
UNKNOWN (20-25%)
THYROID STORMBURCH AND WARTOFSKY’S DIAGNOSTIC PARAMETERS AND
SCORING
>45 highly suggestive of TS25-44 suggestive of impending TS<25 unlikely TS
THYROID STORM
LABORATORY EVALUATION
• elevated Free T4 and FreeT3 levels
• Low TSH
• Chem 8 (low Cr, high Ca)
• CBC (low platelets)
• LFTs (elevated transaminases)
• blood cultures
THYROID STORM
IMAGING
• CXR (or CT chest w/o contrast)
• Thyroid sonogram
• CT neck
• Nuclear medicine imaging with iodine-131
THYROID STORM
TREATMENT
1. Supportive care IV fluid ±dextrose Antipyretics No aggressive cooling!
2. Blockade of peripheral conversion of T4T3 Dexamethasone 2-4mg IV q6h OR Hydrocortisone 300 mg IV, then 100mg IV q8h
THYROID STORM
TREATMENT
3. Inhibition of thyroid hormone release PTU 500-1000 mg load then 250 mg Q4 hour (preferred) Methimazole 60-80 mg QD, divided into doses q4-6 hrs
4. Blockade of hormone production (must be done 1 hour after thionamides)
Potassium Iodide 5 drops PO q6 OR Lugol’s Solution 8 drops PO q 6 OR Sodium Iodide 0.5 mg IV Q 12 hours Lithium Carbonate 300 mg q 6-8 (when iodine is contradicted)
THYROID STORMTREATMENT
5. Blockade of peripheral β adrenergic receptors• Propanolol 1-2 mg IV q 15 minutes (for HR ≤ 100 bpm)• Then continue maintenance drip (Max 3- 5 mg/hr) OR
• Esmolol 500 mcg/kg !V bolus• Then 50-200 mcg/kg/min maintenance
6. Treatment of underlying precipitant Abx, thrombolytics, insulin, etc
DISPOSITION
• ICU- All thyroid storm patients
•General medical floor- Thyrotoxicosis patients with serious complaint or comorbities
•Discharge with Endocrine/PMD follow- Hyperthyroid patients with minimal sx
TEACHING POINTS
1.Clinical diagnosis: fever, tachycardia, AMS, GI sx
2. Treat thyroid storm while addressing underlying precipitant
3.Aggressive supportive treatment and appropriate level of care