11/2/16 Resident Morning Report – Thyrotoxicosis, Thyroid Storm

CC: found down and confused in a park

ID: 29 yo Hispanic male was found down and confused in a park.  On arrival to the hospital, exam was notable for orientation only to name, fever to 38.0C, HR to 152, and BP of 150/113.  Labs revealed a urine tox screen positive for amphetamines in addition to TSH 7.77, FT3 > 20, anti-TPO Ab > 1000.  EKG demonstrated sinus tachycardia.  The patient was evaluated by Endocrine and was transferred to the MICU for a propranolol drip and methimazole for severe thyrotoxicosis.  He eventually underwent thyroidectomy and has been doing well post-operatively.

ct-neck
CT neck: Soft tissue asymmetry at the level of the thoracic inlet, left slightly more prominent than right, raising the possibility of diffuse enlargement of the thyroid gland.

Don’t forget:

  • Use the mnemonic MOVE STUPID to help work up altered mental status
    • Metabolic derangements (hypo/hypernatremia, hypercalcemia)
    • Oxygen (hypoxia)
    • Vascular (CVA, intracranial hemorrhage, hypertensive encephalopathy)
    • Endocrine (thyroid disease, hypoglycemia)
    • Seizures
    • Trauma, tumors
    • Uremia, hepatic encephalopathy
    • Psychiatric disease
    • Infection
    • Drugs (illicit, legal, intoxication or withdrawal)
  • Thyroid storm is a clinical syndrome, characterized by thyrotoxicosis, hyperthermia, altered mentation, and a precipitating event (infection, drugs, etc).
  • The Burch-Wartofsky score can be used to help clinicians diagnose thyroid storm.

Pearls from morning report:

  • Avoid salicylates in thyroid storm – they can decrease thyroid protein binding and cause an increase in free thyroid hormone levels, exacerbating symptoms.
  • If methimazole or PTU does not seem to be effective, plasmaphresis is a method to remove free T4 as a last resort.

Random trivia:

Notable celebrities with Graves’ disease include George H.W. Bush, Missy Elliott, Sia Furler, Marty Feldman, and Maggie Smith.


Want to read more?

Graves’ Disease (New England Journal of Medicine)
Thyrotoxicosis and the Heart (New England Journal of Medicine)


References: 

Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. J Clin Endocrinol Metab. 2015; 100(2):451-9.

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