33M with no PMH presented to the ED with one day of palpitations, complicated by a week of nausea, non-bloody non-bilious emesis, generalized weakness. On physical exam, the patient is diaphoretic, tachycardic with atrial flutter to 140s, febrile to 103F, initially AO x3, but now becoming drowsy and fatigued. The patient denies headache, neck stiffness, cough, dysuria, abdominal pain, skin changes. An astute medical student notes a goiter on neck exam.
What is the diagnoses?
Thyroid Storm, a difficult lethal diagnoses to make, one which has a mortality of 20-30%. To aid you in the diagnoses, there is the Burch and Wartofsky scoring system where a score >45 is suggestive of thyroid storm. Diagnoses is made clinically and is confirmed by thyroid function testing.
Now that you’ve made that difficult diagnoses, how do we treat them?
1st. Beta-blocker, Esmolol gtt v. Propranolol po; Steroids (aiding as an antinflammatory agent and in possible adrenal insufficiency)
2nd. PTU vs. methimazole vs. Lithium
What if they continue to be in extremis?
Several case reports have reported decreasing free T4 and possible decreased mortality with plasmapheresis. The mechanism is not completely understood but the theory is; 1. thyroid-binding globulin bound to active hormone is removed, then 2. infusion of albumin, given as colloid repletion, aids in hormone binding thereby decreasing free T4.
BMJ Case Reports 2012; doi:10.1136/bcr-2012-006696 (case reports/review)
J Clin Apher 2010;25:83–177 (guidelines of plasmaphresis)