Abstract Introduction Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis, with the incidence reported from national surveys being 0.36 per 100,000 persons per year in the United States. Early diagnosis and management are imperative due to the high mortality rate of thyroid storm (ranging from 8 to 25 percent) with admission to the ICU for close monitoring until stabilized. Hospital Course A 22 year old female with a history of recently diagnosed Graves disease presented to the emergency department with acute onset nausea, vomiting, dizziness, palpitations, tremors and chest pressure for one day. She had been taking her methimazole regularly but admitted to missing doses of propranolol. Vital signs on admission were significant for sinus tachycardia. Physical examination was positive for reproducible chest pain. Blood work revealed an elevated troponin (310), TSH 0.01 and free Thyroxine (T4) 24, consistent with severe thyrotoxicosis. EKG was negative for ischemic changes making demand ischemia the likely cause of the troponinemia, and troponins down trended shortly after. The Burch-Wartofsky Point Scale (BWPS) score was 25, based on tachycardia 120 and gastrointestinal symptoms suggestive of impending thyroid storm. Endocrinology was consulted, and the patient was admitted to the ICU for closer monitoring. Methimazole 40 mg daily, propranolol 20 mg every 6 hours, and hydrocortisone 25 mg twice daily were started. Daily thyroid function tests were also obtained. The patient’s clinical course was notable for rapid improvement in symptoms, vital signs and laboratory values with improvement of tachycardia and decrease of T4 to 21.3 by day 2 of hospitalization, with subsequent transfer out of the ICU and discharge by Day 4. Discussion The case highlights the importance of early recognition and management of thyroid storm to prevent morbidity and mortality. While the American Thyroid Association recommends clinical diagnosis of thyroid storm, scoring systems such as BWPS are also important in helping guide management, with more aggressive therapy for BWPS ≥45 and discretion of the clinician for management of scores 25-44. The American Thyroid Association and the American Association of Clinical Endocrinology advocate a multimodal approach, including antithyroid drugs(thionamides), β-blockade, corticosteroids, iodine therapy and supportive care in the ICU. This abstract is funded by: None
Butt et al. (Fri,) studied this question.
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