Endocrine Abstracts

Introduction: Thyroid storm (TS) is a severe manifestation of thyrotoxicosis, (1). It is most commonly seen in Graves’ disease and can occur due to a non-compliance to anti-thyroid medications Management includes both addressing end organ damage and attaining a euthyroid state. We report the case of a patient who presented a thyroid storm complicating a grave’s disease and unmasking, during its management, a corticotropic insufficiency.

Clinical Case: Fifty one year-old patient, diagnosed since 10 months with grave’s disease under anti-thyroid-drugs (ATD) with non compliance, Admitted to the emergency department for vomiting, abdominal pain and fever. Clinically, we noted blood pressure at 16/10 cmhg, heart rate 146, temperature 38.7°C, widespread abdominal tenderness. Biological tests: TSH us <0.001, fT4>100 pmol/l, fT3: 38, 25 pmol/l, with hepatic cytolysis, CRP: 127 mg/l, WBC: 14610. Thyroid storm was retained and patient undergone plasmapheresis. After an intensive care stay and challenging surgery preparation following deterioration in clinical condition and of biological parameters, a total thyroidectomy was performed without malignant signs in histological study. In the post-operative period, the patient began to experience arterial hypotension reaching 80/40 mmgh, and started vomiting again. Adrenal crisis suspected and 8 h cortisol was: 9 mg/dl. Treatment of an acute adrenal crisis was started with rehydration and bolus of intravenous HSHC with oral hydrocortisone relay, clinical and biological improvement. During follow-up, the patient revealed that she had been self-medicating with corticosteroid (dexamethasone) to gain weight for several years with a sudden stop.

Discussion: Symptoms that highly correlate with thyroid storm include fever ≥38°C, tachycardia ≥130 beats per minute, central nervous system manifestations, congestive heart failure, and gastrointestinal/ hepatic manifestations. First line therapy is represented by: antithyroid drugs, beta-adrenergic blockers, potassium iodid, glucocorticoids, antipyretics. If severe symptoms persist or no improvement, contrindications or toxicity, plasmapheresis is indicated before radical treatment (2). Our patient has non compliance of ATD and his body probably remained in a state of thyrotoxicosis which, in the presence of unrecognized adrenal insufficiency, led to a thyroid storm. Thyroid storm, initially masked adrenal insufficiency, but after surgery the clinical picture was transformed and corticotropic insufficiency due to prolonged corticosteroides self medication has been unmasked.

Conclusion: Our clinical case illustrates the difficulty of diagnosis in the case of association between thyroid storm and adrenal crisis and emphasizes the importance of questioning and physical examination in therapeutic management.

Keywords: thyroid storm, anti-thyroid drugs, thyroidectomy, adrenal crisis.