Download as PDF, PPTX
Uploaded byDr Karthik Balachandran
Thyroid storm
This document discusses the case of a 56-year-old woman who presented with fever, sore throat, and breathlessness and was diagnosed with thyroid storm. It provides details on her medical history, examination, labs, and treatment. The document also discusses two additional cases of thyroid storm and provides a summary of key points on diagnosing and treating thyroid storm.
More Related Content
Similar to Thyroid storm
Thyroid storm
- 1.
- 2.
- 3. Case 1 • 56year female • k/c/o hyperthyroidism, diagnosed as Graves disease elsewhere when she presented with weight loss, palpitations, tremors • Lost follow up after lockdown • Developed fever and sorethroat • Tested twice for COVID19- negative • Breast cancer survivor, operated 7 years back • No cardiac history Karthik Thyroid Storm December 6, 2020 3 / 46
- 4. Course … • Admittedto the ICU • Developed breathlessness and tachycardia • Found to have an unimpressive goiter • No jaundice Karthik Thyroid Storm December 6, 2020 4 / 46
- 5. Relevant Labs … ParameterValue Sodium 134 mEq/L Potassium 4 mEq/L FT3 9.2 pg/ml FT4 4.05 ng/dl TSH <0.01 mIU/L Hb 10.1 gm/dl Total Count 1400 ANC 560 ALT 45 IU/L Karthik Thyroid Storm December 6, 2020 5 / 46
- 6. Could it bestorm? Suspect a storm in any sick thyroid patient, even if you have never seen a storm before There is no clean cut off of T3/T4/TSH to differentiate ’routine’ thyrotoxicosis from thyroid storm Clinical points Karthik Thyroid Storm December 6, 2020 6 / 46
- 7. Thyroid storm Thyrotoxicosis Systemic decompensation Trigger KarthikThyroid Storm December 6, 2020 7 / 46
- 8. What is this? StormAgranulocytosis Karthik Thyroid Storm December 6, 2020 8 / 46
- 9. How to diagnose? BurchWartofsky score • Thermoregulatory dysfunction • Cardiovascular manifestations • Tachycardia • Atrial fibrillation • Congestive heart failure • Gastro intestinal / hepatic dysfunction • CNS dysfunction • Precipitating history Total score: ≥ 45 - thyroid storm, 25–44: impending thyroid storm, <25: unlikely thyroid storm Karthik Thyroid Storm December 6, 2020 9 / 46
- 10. How common isthe storm?1 1 < 1 % of patients with thyrotoxicosis develop storm Karthik Thyroid Storm December 6, 2020 10 / 46
- 11. Double trouble Storm Agranulocytosis KarthikThyroid Storm December 6, 2020 11 / 46
- 12. Returning to thedrug records What drug was the patient taking and what dose? Both PTU and Methimazole can cause agranulocytosis, but PTU in addition has a much higher risk of hepatotoxicity and ANCA+ vasculitis Clinical points Karthik Thyroid Storm December 6, 2020 12 / 46
- 13. Returning to thedrug records What drug was the patient taking and what dose? Both PTU and Methimazole can cause agranulocytosis, but PTU in addition has a much higher risk of hepatotoxicity and ANCA+ vasculitis Clinical points The patient was taking carbimazole 10 mg 1-1-1 Karthik Thyroid Storm December 6, 2020 12 / 46
- 14. Treatment options Principles oftreatment 1 Stop production of thyroid hormone 2 Stop further release of thyroid hormone 3 Stop action of already released thyroid hormone 4 Take care of systemic actions that have already happened Karthik Thyroid Storm December 6, 2020 13 / 46
- 15. Drug menu Drug Principle MMI/CarbimazoleStop production PTU Stop production Potassium perchlorate Stop production Iodine(SSKI / Lugol’s) Stop release Lithium Stop release Cholestyramine Stop action β blockers Stop action Steroids Stop action Karthik Thyroid Storm December 6, 2020 14 / 46
- 16. Choices When one thionamidecauses serious toxicity (vascular/hepatic/hematologic), it can’t be replaced by another thionamide Perchlorate has two problems - availability & aplastic anemia Lithium + Iodine ≯ Lithium or Iodine Clinical points Karthik Thyroid Storm December 6, 2020 15 / 46
- 17. Non pharmacologic options •Plasmapheresis • Charcoal and resin hemoperfusion Karthik Thyroid Storm December 6, 2020 16 / 46
- 18. Plasmapheresis • Large volumeplasmapheresis • Removes TBG with bound hormone & antibodies • Removes ≈ 20 % of the T4 pool & even less of the T3 pool during the procedure • Effect is transient (24 to 48 hours) Karthik Thyroid Storm December 6, 2020 17 / 46
- 19. Back to ourpatient … Problems • Impending storm • Agranulocytosis • ? Sepsis 2 2 Blood culture was negative,but can’t rule out systemic infection Karthik Thyroid Storm December 6, 2020 18 / 46
- 20. Options Pharmacologic options forthyroid control in our patient • Lithium • Cholestyramine • Steroids • β blockers • Supportive care Karthik Thyroid Storm December 6, 2020 19 / 46
- 21. Supportive care isextremely important
- 22. Supportive care • Antipyretics- paracetamol, external cooling • Check for access - iv, oral / rectal • Broad spectrum antibiotics • Fluid management • Glycogen depletion - prefer Dextrose containing fluids • May be thiamine deficient - add Thiamine to prevent Wernicke’s encephalopathy, especially in alcoholics Salicylates should not be given - they ↓ protein binding & ↑ freehormone levels Caution Karthik Thyroid Storm December 6, 2020 21 / 46
- 23. Course … • Stoppedmethimazole • Lithium 300 mg Q 8 hrly • Dexamethasone 2 mg iv Q 8 hrly • Propranolol 40 mg Q 6 hrly 3 • Meropenem + levofloxacin • Filgrastim (G-CSF) - 75 µg / day Plan : Defitive treatment (surgery or radioiodine ablation after stabilization 3 T → T3 conversion blockade happens at high doses >160 mg/dl Karthik Thyroid Storm December 6, 2020 22 / 46
- 24. Day 5 … •Fever improved • Counts increased to 8000/µL • Beta blockers tapered • Shifted to HDU Karthik Thyroid Storm December 6, 2020 23 / 46
- 25. Day 6 … KarthikThyroid Storm December 6, 2020 24 / 46
- 26. Mimics Karthik Thyroid StormDecember 6, 2020 25 / 46
- 27. What went wrong? •G-CSF induced rapid expansion of cell pool Karthik Thyroid Storm December 6, 2020 26 / 46
- 28. What went wrong? •G-CSF induced rapid expansion of cell pool • Hypokalemia Karthik Thyroid Storm December 6, 2020 26 / 46
- 29. What went wrong? •G-CSF induced rapid expansion of cell pool • Hypokalemia • Tapering of beta blockers Karthik Thyroid Storm December 6, 2020 26 / 46
- 30. What went wrong? •G-CSF induced rapid expansion of cell pool • Hypokalemia • Tapering of beta blockers • High levels of thyroid hormone Karthik Thyroid Storm December 6, 2020 26 / 46
- 31. Course • Electrolyte abnormalitiescorrected • Managed with cardiologist • Surgery vs radioiodine ablation choice - decided on radioiodine ablation • 3 month follow up - the patient is better Karthik Thyroid Storm December 6, 2020 27 / 46
- 32. Learning point Just likeany other medical emergency be prepared for second order complications in thyroid storm Karthik Thyroid Storm December 6, 2020 28 / 46
- 33.
- 34. History • 30 yearmale, weight loss & hyperdefecation for several weeks • Symptoms deteriorated - confusion • Brought to emergency • Past hx - methimazole 7 months back, underwent wisdom tooth extraction 4 weeks back • Younger brother has type 1 diabetes Karthik Thyroid Storm December 6, 2020 30 / 46
- 35. Examination Pulse 140 bpm Temp101 ◦ F Resp 25 breaths/min Eye Graves ophthalmopathy Karthik Thyroid Storm December 6, 2020 31 / 46
- 36. Labs Parameter Value TSH <0.001mIU/L FT4 8.1 ng/dl ALT 80 U/L AST 78 U/L Sodium 137 mEq/L Potassium 4.5 mEq/L Karthik Thyroid Storm December 6, 2020 32 / 46
- 37. Diagnosis Burch Wartofsky score •Thermoregulatory dysfunction • Cardiovascular manifestations • Tachycardia • Atrial fibrillation • Congestive heart failure • Gastro intestinal / hepatic dysfunction • CNS dysfunction • Precipitating history Total Score: 80 Karthik Thyroid Storm December 6, 2020 33 / 46
- 38. Thyroid storm Thyrotoxicosis Systemic decompensation Trigger KarthikThyroid Storm December 6, 2020 34 / 46
- 39. Learning points Young patientscan develop storm too Stopping drugs is a common precipitant CNS symptoms are an easy clue Karthik Thyroid Storm December 6, 2020 35 / 46
- 40.
- 41. History • 60 yearmale with fever, weight loss, fatigue • h/o CLL - received Rx with bendamustine + rituximab • Admitted to ICU with febrile neutropenia Karthik Thyroid Storm December 6, 2020 37 / 46
- 42. Examination Temp 102.5 ◦F Pulse 132 bpm PE Left sided neck swelling ,tender on palpation Karthik Thyroid Storm December 6, 2020 38 / 46
- 43. Labs Parameter Day 1 TSH0.02 FT4 6 ng/dl TC 66,900/µL Monocyte 98% Karthik Thyroid Storm December 6, 2020 39 / 46
- 44. Imaging • CT -lymphomatous nodules in lung, spleen, liver & kidney • Thyroid gland normal Karthik Thyroid Storm December 6, 2020 40 / 46
- 45. Labs Parameter Day 1Day 3 TSH 0.02 - FT4 6 ng/dl >8 ng/dl TC 66,900/µL - Karthik Thyroid Storm December 6, 2020 41 / 46
- 46. Labs Parameter Day 1Day 3 TSH 0.02 - FT4 6 ng/dl >8 ng/dl TC 66,900/µL - Poor response to methimazole Karthik Thyroid Storm December 6, 2020 41 / 46
- 47. Imaging • CT -progression of lymphomatous lesions • Infiltration of thyroid gland • Plasmapheresis planned, but patient succumbed Karthik Thyroid Storm December 6, 2020 42 / 46
- 48. Learning points All neutropeniain patients on ATDs are not due to ATD Cause of thyrotoxicosis matters Time is life, like any other emergency Karthik Thyroid Storm December 6, 2020 43 / 46
- 49. Summary-Diagnosis Thyrotoxicosis Search for thecause Systemic feature Burch Wartofsky score Doubt → Rx Trigger Search Neutralize Karthik Thyroid Storm December 6, 2020 44 / 46
- 50. Summary-Diagnosis Thyrotoxicosis Search for thecause Systemic feature Burch Wartofsky score Doubt → Rx Trigger Search Neutralize Suspicion is the most important step Key Karthik Thyroid Storm December 6, 2020 44 / 46
- 51. Summary-Treatment Principle øProduction : MMI/PTU øRelease :Li / Iodine øAction : Steroid/β blocker Complications Supportive care Anticipation Definitive Rx Ablation Surgery Karthik Thyroid Storm December 6, 2020 45 / 46
- 52. Thank you ! Thispresentation can be downloaded from www.medicalruminations.wordpress.com cbna