Endocrine Abstracts

Background: Thyrotoxicosis is one of the commonest endocrine disorders and its severe form can manifest as thyroid storm in acute setting leading to organ dysfunctions including heart failure.

Cases: 1: A 58-year-old female with a significant past medical history of MI, paroxysmal AF/atrial flutter, and hyperthyroidism presented with a one-week history of palpitations, plethora, diaphoresis, heat intolerance, loose stools, and a TSH <0.01; Free T4-33. On physical exam, patient was warm and well perfused, minimal pedal edema. She was in fast AF. She was medically managed carbimazole, b-blockers and steroids 2: A 28-year-old female with past medical history of asthma and a current smoker. Patient presented with palpitations, anxiety, diarrhea, fatigue, and 2 stone weight loss in 6 months. On physical examination the patient had a smooth, painless goiter, carotid bruits and prominent exophthalmos. The patient was tachycardic (HR 163), and febrile (38.1 C) with elevated CRP 42 and T4 58 TSH<0.01 She was medically managed with Propylthiouracil 100 mg tds; Propranolol 40 mg TDS Prednisolone 30 mg OD 3. 39-year-old patient with known hyperthyroidism presents with palpitations, anxiety. She was found to have swollen legs and was tachycardic at 110 bpm. CXR showed bilateral shadowing suggestive of fluid overload. Blood tests: TSH <0.01, T4 >100, TSH receptor positive. 4.64-year-old lady presented with for 4 months of breathlessness. Found to be in thyrotoxicosis, atrial fibrillation (AF) as well as peripheral oedema. Blood test showed FT4 69 pmol, positive TSH –receptor antibodies. Treated with rate controlling medications, propylthiouracil, steroids and diuretics

Discussion: Thyroid storm is on the severe end of the thyrotoxicosis spectrum, and it is usually triggered by a secondary external event such as infection, myocardial infarction, trauma or surgery. The Burch Wartfosky point scale is used to diagnose thyroid storm. In this scale, the following are assessed: Temperature, cardiovascular dysfunction, central nervous system derangements, gastrointestinal symptoms and heart failure. A score greater than or equal to 45 aligns with a clinical diagnosis of thyroid storm, and scores between 25 and 44 suggest thyroid storm as a likely diagnosis. Scores below 25 points make a diagnosis of thyroid storm unlikely.

Conclusion: Thyroid storm is medical and an endocrine emergency and appropriate and timely treatment will ensure better patient care and outcome In an emergency like acute thyrotoxicosis or thyroid storm, higher doses of thionamides, beta blockers as well as glucocorticoids can be used to return the patient to a euthyroid state.