Thyroid Storm

Patient Presentation:
L.B., a 28 year old female presented to the Emergency Department’s triage room on a hot summer evening stating: “My heart is racing and I am burning up. I feel so nauseous.” The patient was diaphoretic and seemingly agitated from the triage questions. Her vital signs were: T-38.7, P-124, BP-169/92, RR-24, SaO2 - 98%, and pain 7/10 in the abdomen. Upon further triage, it was discovered that the patient was diagnosed 1 week ago with pneumonia at her PMD office and that she had suddenly lost her job 2 days ago. She reported recent weight loss along with nausea, vomiting, and diarrhea for the last few hours.

Differential List:
The triage nurse immediately thought of differential diagnoses in order to assign an appropriate triage level and ED room. Differentials include: anxiety attack, sepsis, drug toxicity, hypertensive encephalopathy, thyroid storm, supra-ventricular tachycardia, or meningitis. Because of the acute nature of the patient’s symptoms and her unstable vital signs, the patient was made a level 2 and immediately brought to a room with a cardiac monitor.

Diagnosis:
In order to diagnose the patient, the MD ordered an EKG (sinus tachycardia), a chest x-ray (marked improvement from her recent pneumonia but negative for any significant findings), a urinalysis and urine toxins screen (both negative), a spinal tap with CSF analysis (negative for WBC and normal glucose levels), along with BMP (normal), CBC (mild leukocytosis), LFT (all elevated), blood cultures x2 (later found to be negative), T3, T4, and TSH (elevated T3, elevated T4 and free T4, and low TSH). The patient was concluded to have hyperthyroid disease and was specifically in acute “thyroid storm”. The longer a patient goes untreated, the greater likelihood of irreversible progression to death.

Treatment:
Treatment for the patient was initiated immediately. Propranolol was administered IV for the patient’s tachycardia. Tylenol was given PO and a cooling blanket was placed on the patient for her fever. Glucocorticoids were given to block peripheral conversion of T3 and T4. Methimazole was given to prevent new thyroid hormone synthesis. IVF were given carefully to replace volume depleted by vomiting and diarrhea. Once stabilized, the patient was transferred to the ICU. The patient’s abdominal pain was managed with morphine and eventually ceased as the pain/GI upset is typically a side effect of thyroid storm that does not indicate any real GI problem. Eventually, the patient’s thyroid was removed and she was expected to make a full recovery.

Outcome:
Outcome from thyroid storm depends on the prompt management of symptoms. Untreated, thyroid storm is almost always fatal. However, with combined medical and surgical treatments, most patients are expected to make full recoveries. The death rate has dropped from almost 100% in the early 1900s to ~20%. Follow-up for these patients include having their thyroid levels regularly checked. Those with thyroidectomy need to be on medications for hypothyroidism.
Case created by Laura Badalamenti, 2010.