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.

1. Thyroid Storm
Karthik Balachandran
karthik2k2

2. Case 1

3. Case 1
• 56 year 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
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4. Course …
• Admitted to the ICU
• Developed breathlessness and tachycardia
• Found to have an unimpressive goiter
• No jaundice
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5. Relevant Labs …
Parameter Value
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
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6. Could it be storm?
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
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7. Thyroid storm
Thyrotoxicosis Systemic
decompensation
Trigger
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8. What is this?
Storm Agranulocytosis
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9. How to diagnose?
Burch Wartofsky 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
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10. How common is the storm?1
1
< 1 % of patients with thyrotoxicosis develop storm
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11. Double trouble
Storm Agranulocytosis
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12. Returning to the drug 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
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13. Returning to the drug 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
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14. Treatment options
Principles of treatment
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
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15. Drug menu
Drug Principle
MMI/Carbimazole Stop 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
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16. Choices
When one thionamide causes 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
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17. Non pharmacologic options
• Plasmapheresis
• Charcoal and resin hemoperfusion
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18. Plasmapheresis
• Large volume plasmapheresis
• 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)
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19. Back to our patient …
Problems
• Impending storm
• Agranulocytosis
• ? Sepsis 2
2
Blood culture was negative,but can’t rule out systemic infection
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20. Options
Pharmacologic options for thyroid control in our patient
• Lithium
• Cholestyramine
• Steroids
• β blockers
• Supportive care
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21. Supportive care is extremely 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
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23. Course …
• Stopped methimazole
• 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
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24. Day 5 …
• Fever improved
• Counts increased to 8000/µL
• Beta blockers tapered
• Shifted to HDU
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25. Day 6 …
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26. Mimics
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27. What went wrong?
• G-CSF induced rapid expansion of cell pool
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28. What went wrong?
• G-CSF induced rapid expansion of cell pool
• Hypokalemia
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29. What went wrong?
• G-CSF induced rapid expansion of cell pool
• Hypokalemia
• Tapering of beta blockers
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30. What went wrong?
• G-CSF induced rapid expansion of cell pool
• Hypokalemia
• Tapering of beta blockers
• High levels of thyroid hormone
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31. Course
• Electrolyte abnormalities corrected
• Managed with cardiologist
• Surgery vs radioiodine ablation choice - decided on radioiodine ablation
• 3 month follow up - the patient is better
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32. Learning point
Just like any other medical emergency be prepared for second order complications
in thyroid storm
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33. Case 2

34. History
• 30 year male, 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
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35. Examination
Pulse 140 bpm
Temp 101 ◦ F
Resp 25 breaths/min
Eye Graves ophthalmopathy
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36. Labs
Parameter Value
TSH <0.001 mIU/L
FT4 8.1 ng/dl
ALT 80 U/L
AST 78 U/L
Sodium 137 mEq/L
Potassium 4.5 mEq/L
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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
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38. Thyroid storm
Thyrotoxicosis Systemic
decompensation
Trigger
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39. Learning points
Young patients can develop storm too
Stopping drugs is a common precipitant
CNS symptoms are an easy clue
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40. Case 3

41. History
• 60 year male with fever, weight loss, fatigue
• h/o CLL - received Rx with bendamustine + rituximab
• Admitted to ICU with febrile neutropenia
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42. Examination
Temp 102.5 ◦ F
Pulse 132 bpm
PE Left sided neck swelling ,tender on palpation
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43. Labs
Parameter Day 1
TSH 0.02
FT4 6 ng/dl
TC 66,900/µL
Monocyte 98%
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44. Imaging
• CT - lymphomatous nodules in lung, spleen, liver & kidney
• Thyroid gland normal
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45. Labs
Parameter Day 1 Day 3
TSH 0.02 -
FT4 6 ng/dl >8 ng/dl
TC 66,900/µL -
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46. Labs
Parameter Day 1 Day 3
TSH 0.02 -
FT4 6 ng/dl >8 ng/dl
TC 66,900/µL -
Poor response to methimazole
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47. Imaging
• CT - progression of lymphomatous lesions
• Infiltration of thyroid gland
• Plasmapheresis planned, but patient succumbed
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48. Learning points
All neutropenia in patients on ATDs are not due to ATD
Cause of thyrotoxicosis matters
Time is life, like any other emergency
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49. Summary-Diagnosis
Thyrotoxicosis
Search for the cause
Systemic feature
Burch Wartofsky score
Doubt → Rx
Trigger
Search
Neutralize
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50. Summary-Diagnosis
Thyrotoxicosis
Search for the cause
Systemic feature
Burch Wartofsky score
Doubt → Rx
Trigger
Search
Neutralize
Suspicion is the most important step
Key
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51. Summary-Treatment
Principle
øProduction :
MMI/PTU
øRelease : Li / Iodine
øAction : Steroid/β
blocker
Complications
Supportive care
Anticipation
Definitive Rx
Ablation
Surgery
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52. Thank you !
This presentation can be downloaded from
www.medicalruminations.wordpress.com
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