Thyroid storm or thyrotoxic crisis is a manifestation of an extreme state of thyrotoxicosis. It is both rare and potentially fatal. Its presentation can be clouded by the precipitating illness and the involvement of one or more organ systems underlining the importance of clinical suspicion, early recognition and prompt intervention.
We present a case of a 37-year-old man presenting to hospital with a community acquired chest infection that had not settled with oral antibiotics from his general practitioner. Twenty-four hours into the admission he suddenly deteriorated developing hypotension (BP 80/60 mmHg), fast atrial fibrillation and pulmonary oedema.
Past history included Graves disease but he had been non compliant with treatment for the preceding 8 months. Although he was initially thought to have sepsis secondary to pneumonia with associated cardiogenic shock, his thyroid function tests indicated severe thyrotoxicosis: TSH<0.05 (normal 0.24 mU/l), free T3 29.9 (normal 2.55.7 pmol/l), free T4 46 (normal 924 pmol/l). This along with the clinical picture of thyrotoxic state was consistent with a diagnosis of thyroid storm.
Prompt anti thyroid medications and supportive management on intensive care was instituted. This included carbimazole (later changed to propylthiouracil), Lugols iodine and high dose dexamethasone along with broad spectrum antibiotics, inotropic and ventilatory support. Recovery was complicated by liver dysfunction and renal failure requiring haemo-filtration for a short period.
His thyroid function improved alongside his response to treatment. Following 2 weeks on intensive care he made a remarkable recovery. After discharge his thyrotoxicosis was successively treated as an out-patient with two separate courses of radioiodine.
This case serves to remind us of this rare form of severe thyrotoxicosis. In this case it had occurred complicating sepsis. It also demonstrates the multiple organ systems that can be involved and the importance of prompt and aggressive multifaceted therapeutic intervention.