28 you F with no known PMH, p/w palpitations x 3 days after bus trip to Washington DC, states she is feeling “awful”, symptoms have been constant and worsened today.  Also endorses b/l LE swelling, nausea, vomiting x1 per day, fatigue, diaphoresis, mild SOB.  Notes generalized yellowing of skin.  Denies CP, no fevers, no cough.  No sick contacts, no travel outside of the country.

Endorses occasional etoh abuse, no tobacco, no other drug use

 

Exam:

VS: 96.6, 147, 156/56, 22, 100% RA

Gen: anxious, diaphoretic, jaundice

HEENT: +scleral icterus, mmm

CVS: irregularly irregular, tachycardic, no m/r/g

Resp: CTAB

Abd: soft, NTND, no appreciable hepatomegaly

Ext: 2+ pitting edema b/l

Neuro: A/Ox3, nonfocal

 

EKG: rapid afib

 

Notable labs:

Platelets 26

PT/PTT/INR 30/66/2.6

Tbili/Dbili 13.5/5.5

AST/ALT/AlkP 137/51/208

GGT/LDH 26/446

Lactate 4.5

Negative urine pregnancy

CXR: cardiomegaly

Biggest concern?

THYROID STORM

Burch and Wartofsky’s diagnostic criteria for thyroid storm:
Thermoregulatory dysfunction
Temperature (°F | °C)
99 to 99.9 | 37.2 to 37.7 5
100 to 100.9 | 37.8 to 38.2 10
101 to 101.9 | 38.3 to 38.8 15
102 to 102.9 | 38.9 to 39.4 20
103 to 103.9 | 39.4 to 39.9 25
≥104.0 | >40.0 30
Central nervous system effects
Mild 10
Agitation
Moderate 20
Delirium
Psychosis
Extreme lethargy
Severe 30
Seizure
Coma
Gastrointestinal-hepatic dysfunction
Moderate 10
Diarrhea
Nausea/vomiting
Abdominal pain
Severe 20
Unexplained jaundice
Cardiovascular dysfunction
Tachycardia
99 to 109 5
110 to 119 10
120 to 129 15
130 to 139 20
≥140 25
Atrial fibrillation 10
Heart failure
Mild 5
Pedal edema
Moderate 10
Bibasilar rales
Severe 15
Pulmonary edema
Precipitant history
Negative 0
Positive 10

A score of 45 or more is highly suggestive of thyroid storm; a score of 25 to 44 supports the diagnosis; and a score below 25 makes thyroid storm unlikely.

 

This patient has a score of 80, in patients with probable thyroid storm, which is a clinical diagnosis, you should go ahead and treat without confirmatory studies because mortality from this disease is very high (at least 30% with some sources asserting that delay of treatment may increase mortality to 75%)

 

Treatment:

1. Beta blockers (Propranalol), treats symptoms

2. Methimazole or PTU, block synthesis of thyroid hormone

3. Iodine, blocks release of thyroid hormone, this must be given after a synthesis blocking agent!!!

4. Steroids, block conversion of T4 to T3

 

References:

Dr. Zara Mathews

http://www.uptodate.com/contents/thyroid-storm?source=machineLearning&search=thyroid+storm&selectedTitle=1~94&sectionRank=2&anchor=H13827326#H

S. Karger and D. Führer, “Thyroid storm—thyrotoxic crisis: an update,” Deutsche Medizinische Wochenschrift, vol. 133, no. 10, pp. 479–484, 2008.