Endocrine Abstracts

JOINT2632

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

Case Presentation: A 50-year-old man presented to the emergency department (ED) with a 3-week history of weight loss, palpitations, tremors, breathlessness, and leg swelling. He was initially discharged from the hospital with furosemide as a suspected diagnosis of heart failure. Chest-X-ray on admission demonstrated clear lungs fields. An echocardiogram after admission demonstrated normal left ventricular function (LVEF > 55%), normal right ventricular function, mild MR and Pasp 22-27 mmHg. He was initially discharged with furosemide as a suspected diagnosis of heart failure. Patient remained feeling unwell and his GP performed further blood tests which showed a suppressed TSH and a free T4 >100, T3 35. ALT 53, Calcium 2.72. He was subsequently referred to the Acute Medicine Department at Queens Hospital. Upon review, there were clear symptoms of thyrotoxicosis. His lower limb swelling had improved with the furosemide prescribed previously. His Burch-Wartofsky Score was 30 suggestive of impending thyroid storm. The case was reviewed by an endocrinologist and the following medications were commenced:

• 4g once daily Cholestyramine 2weeks

• 30 mg Prednisolone 5days (following stat-dose hydrocortisone 100 mg IV in ED)

• 20 mg twice daily Carbimazole

• 20 mg three times a day Propranolol (following stat-dose 40 mg in ED)

• Furosemide 40 mg once daily He was followed up in the Endocrine clinic and his symptoms had improved

Discussion: Thyrotoxicosis is a life-threatening complication of hyperthyroidism, clinically it is manifested as thyroid storm and triggered by a secondary external event such as infection, myocardial infarction, trauma or surgery. It is crucial to identify the underlying aetiology leading to the severe clinical manifestation of thyroid storm to start appropriate treatment. The consequence of delayed diagnosis and lack of correct treatment can lead to further complication such as delirium, thromboembolic disease, cardiovascular collapse and eventually death. Currently, the Burch Wartfosky point scale is used to diagnose thyroid storm. A score greater than or equal to 45 aligns with a clinical diagnosis of thyroid storm.

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