SFENCC2021 Abstracts Highlighted Cases (71 abstracts)
Learning to weather the storm: a case highlighting the challenges of managing a thyrotoxic crisis in a ventilated, co-morbid patient
Section 1: Case history: A 60-year-old woman was transferred to the receiving hospital after thrombolysis for a left-sided total anterior circulation stroke. Her past medical history was significant for alcohol dependence (70 units/week), atrial fibrillation (not anticoagulated but rate controlled with propranolol), seizures and severe mitral regurgitation. This lady underwent a successful thrombectomy, but subsequently developed haemorrhagic transformation and hydrocephalus. She was transferred to ICU for an external ventricular drain insertion which was removed after improving radiological imaging. The patient remained intubated and ventilated. During this time she became pyrexic, had multiple seizures and increasingly fast AF, consistent with a thyroid storm.
Section 2: Investigations: On admission to hospital thyroid function tests were sent as part of her assessment for atrial fibrillation, showing TSH <0.02 mIU/l, and free T4 36.2 pmol/l. Unfortunately, the results were not checked and no action was taken. Following her clinical deterioration with pyrexia and seizures her TFTs were repeated which revealed a TSH <0.02 mIU/k, Free T4 70.7 pmol/l and Free T3 25.3 pmol/l. Treatment was commenced with IV propranolol, propothyouracil, iodine and hydrocortisone. However, following this episode the patient developed a significant lactic acidosis (4.0 mmol/l to 12.5 mmol/l), and hyperkalaemia (3.4 mmol/l to 11.0 mmol/l) over the course of 4 hours. She also became increasingly hypotensive despite aggressive fluid resuscitation and vasopressor support.
Section 3: Results and treatment: Clinical examination revealed a soft abdomen producing liquid stool. A CT angiogram was requested for suspected mesenteric ischaemia. During transfer to CT this lady had a cardiac arrest and resuscitation efforts were unsuccessful. Subsequent pending TRAb results were measured at 13 IU/l, supporting a diagnosis of Grave’s disease.
Section 4: Conclusions and points for discussion: This lady displayed symptoms consistent with a thyrotoxic storm including: pyrexia, tachycardia, seizures and diarrhoea in addition to deranged TFTs. Her Burch-Wartofsky score was later calculated at 95 points, further supporting this diagnosis. Despite medical management, disease progression resulted in a fatal outcome. Even with targeted treatment, the mortality rate for a thyroid storm remains high. This reinforces the need for prompt investigation and management of suspected hyperthyroidism, particularly in vulnerable patient groups where existing co-morbidities may mask acute progression of symptoms. Additionally, this case highlights the difficulty of diagnosing a thyroid storm in a ventilated, co-morbid patient with previously undiagnosed thyroid disease. It also underlines the importance of having reliable hospital systems to prevent abnormal results being missed.