Follow-Up Rounds (10/2/15)
Article Inspired by: Adelle Iusim, PGY-3
THE CASE:
CC: Body aches, Fever, Left-sided abdominal pain x 3 weeks
Triage Vitals- BP-125/78, HR: 99, RR: 18, SpO2-93%, Temperature: 100.8F
HPI: 25 y/o F presents with abdominal pain (left sided, generalized cramping), subjective fever/chills, and myalgias x 3 days. She reports persistent nausea and vomiting with PO intake. She also endorses urinary frequency and a foul smelling urine.
PMHx: Hyperthyroidism, Seizures(?), Latent tuberculosis
PSHx: none
Meds: cannot recall
Allergies: NKDA
Pertinent positives on physical exam:
HEENT: Dry mucous membranes
Cardiovascular: Tachycardic
Abdomen: BS+ x4, Soft, NT/ND
Back: B/l CVA tenderness
EKG: Sinus tachycardia @130bpm
Differential Diagnosis:
- Infectious:
- Influenza
- Viral Syndrome
- Strep
- Pneumonia
- Encephalitis
- Meningitis
- Intraabdominal pathology
- UTI
- Pyelonephritis
- Cardiovascular/Endocrine:
- Arrythmia
- Hyperthyroidism
- Thyroid Strom
- Toxidrome due to drugs
- Pheochromocytoma
Labs:
Na: 135, K: 4.7, Cl: 102, HCO3: 20.8, BUN: 15, Cr: 0.4, Glu: 97
Ca: 9.3, Mg: 2.2,T. Prot: 8.3, Albumin: 4.1, T. Bili: 1.2, Alk Phos: 232, AST: 25, ALT: 35; AG: 12.2
WBC: 13.5, Hgb: 13.8, Hct: 41.1, Plt: 231, MCV: 81, Gr: 66.9, Lym: 26.2
UA: Cloudy, glucose negative, bili negative, ketones trace, sp grav: 1.02, large blood; +nitrite; large leuk esterase; WBC: 479; RBC: 191; Bacteria 4+; Epithelial 81; Micro: WBC: many, RBC: 7-10, Bacteria: many
CXR- no acute cardiopulmonary process
TSH: <0.008, Free T4: 11.13
Management:
After further questioning (and eliciting palpitations, weight loss, insomnia on ROS) and further examination (significant for mild exopthalmos and hyperreflexia), she was given Tylenol, 1L NS, Ceftriaxone 1g IV and endocrine was called for likely Grave’s disease.
Endocrine consult: Methimazole 30mg orally; Wait 1 hr, give 5 drops of 0.25mL Potassium Iodide sski q6hr; Atenolol 50mg q8hr (with titration to HR of 80); Check TPO and TSI antibody; Consider steroids if patient deteriorates.
Hospital Course:
Continued on Atenolol, Methimazole. Hydrocortisone 100mg q8hr was started, 0.25mL SSKI potassium iodide q6hr was restarted.
Continued treatment with Ceftriaxone for 2 days, and once cultures came back as pansensitive, switched to Ciprofloxacin for 2 days.
TSI 5.9 (<1.3 is normal), Thyroid peroxidase antibody <10 (<35 is normal)
Discharged after 2 days on Atenolol 50mg TID and Methimazole 30mg daily with endocrine outpatient followup.
THE TALK
Thyroid Storm:
- Rare, life threatening exacerbation of hyperthyroid state with 1 or more organ dysfunction
- Unclear etiology-
- Rapid rate of increase in serum thyroid hormone levels
- Increased responsiveness to catecholamines
- Enhanced cellular responses to thyroid hormone
WHEN DOES THYROID STORM OCCUR?
- Systemic insult
- Infection
- Trauma
- Surgery (usually 6-24 hours post)
- Hyperosmolar coma
- Endocrinal insult
- Drug/Hormone-related
- Withdrawal of thyroid medication
- Acute iodine load
- Thyroid gland palpation
- Ingestion of thyroid hormone
- Cardiovascular insult
- Pregnancy related
WHAT EFFECTS CAN IT HAVE ON THE BODY?
- Direct ionotropic and chronotropic effects:
- Decreased systemic vascular resistance
- Increased blood volume
- Increased contractility
- Increased CO
- Exaggeration of hyperthyroidism symptoms:
- Fever (104F-106F)
- Tachycardia >140 beats/min
- Altered Mental Status (agitation, anxiety, delirium, psychosis, stupor, coma)
- Severe nausea, vomiting, diarrhea, abdominal pain, hepatic failure with jaundice
- Congestive heart failure
- Cardiac arrhythmia (severe tachycardia or atrial fibrillation in 10-35% cases)
- Enhanced contractility → elevations in systolic BP and pulse pressure –> dicrotic or water-hammer pulse
- Death
WHAT SHOULD I LOOK FOR IN MY PHYSICAL EXAM?
- Goiter
- Exopthalmous (to think about Grave’s)
- Lid lag
- Hand tremor
- Warm and moist skin
WHAT OTHER DIAGNOSES SHOULD I BE CONSIDERING?
- Infection/Sepsis
- Sympathomimetic ingestion (ex: cocaine, amphetamine, ketamine drug use)
- Heat exhaustion
- Heat stroke
- Delirium tremens
- Malignant hyperthermia
- Malignant neuroleptic syndrome
- Hypothalamic stroke
- Pheochromocytoma
- Medication withdrawal (ex: cocaine, opioids, etc)
- Psychosis
- Organophosphate poisoning
WHAT LAB TESTS SHOULD I ORDER?
- Chemistry
- Creatinine may be low
- Mild hypercalcemia (hemoconcerntration and enhanced bone resorption)
- Mild hyperglycemia (Catecholamine induced inhibition of insulin release and increased glycogenolysis)
- CBC
- Thrombocytopenia
- Leukocytosis or Leukopenia
- TFTs (degree of thyroid hormone excess not more profound than uncomplicated thyrotoxicosis)
- Low TSH
- High free T4 and or T3
- LFTs
- Cortisol level (to rule out concurrent adrenal insufficiency)
IS THERE A CLINICAL TOOL I CAN USE TO DIAGNOSE IT?
Burch and Wartofsky scoring system (sensitive but not very specific)
- Thermoregulatory Dysfunction
- Temp 99 to 99.9F = 5 points
- Temp 100 to 100.9F = 10 points
- Temp 101 to 101.9F = 15 points
- Temp 102 to 102.9F = 20 points
- Temp 103 to 103.9F = 25 points
- Temp > 104F = 30 points
- CNS effects
- Mild (agitation) = 10 points
- Moderate (delirium, psychosis, extreme lethargy) = 20 points
- Severe (seizure, coma) = 30 points
- GI-Hepatic dysfunction
- Moderate (abdominal pain, nausea, vomiting, diarrhea) = 10 points
- Severe (unexplained jaundice) = 20 points
- Cardiovascular dysfunction
- Tachycardia
- HR 99-109 = 5 points
- HR 110-119 = 10 points
- HR 120-129 = 15 points
- HR 130-139 = 20 points
- HR >140 = 25 points
- Atrial fibrillation = 10 points
- Heart Failure
- Mild (pedal edema) = 5 points
- Moderate (bibasilar rales) = 10 points
- Severe (pulmonary edema) = 15 points
- Precipitant history
- Negative = 0 points
- Positive = 10 points
- If score >45: highly suggestive of thyroid storm
- If score 25-44: impending storm
- If score <25: thyroid storm unlikely
HOW DO I MANAGE THIS?
- Supportive care
- IVF with dextrose (to replenish glycogen stores)
- MVI/Thiamine (to prevent Wernicke’s when giving dextrose)
- Tylenol (not NSAIDS or ASA)
- Aspirin can increase serum free T4 and T3 by interfering with protein binding
- Bile acid sequestrants (ex: Cholestyramine- to decrease enterohepatic recycling of thyroid hormones)
- Block peripheral effect of thyroid hormone
- Beta blocker (to control symptoms/signs induced by increased adrenergic tone- slows HR, increases diastolic filling and decreases tremor)
- Stop the production of thyroid hormone
- Thionamide: Methimazole or PTU (slow conversion of T4 to T3 in periphery)
- PTU favored over Methimazole acutely because of PTU’s effect to decrease T4 to T3 conversion
- Methimazole has a longer duration of action, is less hepatotoxic, and over weeks of treatment, may result in more rapid normalized of serum T3 than PTU
- Glucocorticoids (to reduce T4 to T3 conversion, promote vasomotor stability and possible treat associated relative adrenal insufficiency)
- Iodinated radiocontrast agent (to inhibit peripheral conversion of T4 to T3)- not available in US
- Inhibit hormone release
- Iodine solution 1-2 hours after (to decreases release of thyroid hormone from thyroid)
- Delayed for an hour to prevent iodine from being used as substrate for new hormone synthesis
WHAT IF THEIR SCORE IS 25-44 (IMPENDING STORM)?
- Beta blocker (ex: propranolol 60 to 80 mg q4-6hr until HR controlled)- can require high doses because of increased drug metabolism as a result of hyperthyroidism
- Can alternatively use Esmolol (loading dose 250-500mcg/kg, followed by infusion at 50-100mcg/kg per minute)
- If beta blockers contraindicated, can use CCB (ex: Diltiazem)
- Propylthiouracil 200mg q4hr OR Methimazole 20mg q4-6hr
- 1 hour after first dose thionamide taken, Iodine (saturated solution of potassium iodide [SSKI]) 5 drops q6hr OR Lugol’s solution 10 drops q8hr
AND IF THEIR SCORE IS > 45 (LIKELY THYROID STORM)?
In addition to the above,
- Glucocorticoids (Hydrocortisone 100mg IV q8hr)
- Cholestyramine 4g QID
- Treatment of any precipitating factors
- Some patients require fluids while others require diuresis (ex: CHF)
- Tylenol instead of ASA
IS SURGERY EVER AN OPTION?
- Surgery is treatment of choice for patients who cannot take thionamide (ex: due to agranulocytosis or hepatotoxicity or allergy)
- Still require preoperative treatment with:
- Beta blockers (propranolol)
- Glucocorticoids
- Bile acid sequestrants (cholysteramine 4mg orally QID)
- Patients with Grave’s disease: Iodide (SSKI) 5 drops q6hr or Lugol’s 10 drops q8hr)
- If not effective, plasmapheresis (removes cytokines, antibodies and thyroid hormones from plasma)
REFERENCES
Iusim, A. “Follow up Rounds: Thyroid Storm” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Oct 2015. Case Presentation
Ross, Douglas S., MD. “Thyroid Storm.” UpToDate, 12 Feb. 2015. Web.
Tintinalli, Judith E., and J. Stephan. Stapczynski. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 2011.
Weingart, Scott. “Podcast 149 – Thyroid Storm.” Podcast 149- Thyroid Storm. Emcrit, 16 May 2015. Web. <http://emcrit.org/podcasts/thyroid-storm/>.
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