Endocrine Abstracts

Introduction: Graves’ disease (GD), although the most common cause of hyperthyroidism, is relatively uncommon in children, usually manifesting insidiously. Thyroid storm is a well described but rarely seen phenomenon in childhood GD; thyrotoxic crisis is less often discussed and its management can be challenging. We describe a case of GD with thyrotoxic crisis.

Case: A 14-year-old female, known to have inadequately controlled GD for one year, recently relocated to the UK. She presented with acute breathlessness and change in voice and was found to be tachycardic, hypertensive and agitated with significant exophthalmos and large goiter, consistent with thyrotoxic crisis. Acute management with propylthiouracil, propranolol and intravenous hydrocortisone stabilized her but free T4 and T3 levels were unrecordably high for 10 days. Deterioration in liver function necessitated switching to carbimazole, the dose of which was maximized over the next 2 weeks and cholestyramine added to her regimen. Thyroidectomy was planned and Lugol’s iodine commenced, but in view of persistent high free T3 levels with tachycardia and hypertension, it was felt that further optimization of her management was required before surgery could be undertaken safely. Hydralazine and dexamethasone finally brought her blood pressure and thyroid function under control. Lugol’s iodine, which had been stopped, could not be safely restarted prior to surgery in view of its potential detrimental effect on thyroid hormone production. 6 weeks after initial presentation, she was significantly better with free T4 and T3 in the normal range for the first time and improvement in cardiovascular parameters as well as symptoms. She underwent thyroidectomy without complications. Anticipated thyroid storm in the immediate post-operative period did not occur and hypocalcemia was managed with intravenous calcium and alfacalcidol. She was discharged on levo-thyroxine and continues to be monitored closely.

Conclusion: Thyrotoxic crisis complicating pediatric GD is challenging to manage, requires a robust understanding of the different drug treatments and particular attention to the cardiovascular and hemodynamic effects of the toxic state. Our patient required multidisciplinary management between physicians, surgeons, anesthetists and ophthalmologists as well as critical care monitoring in the post-operative period when thyroid storm may still occur.