Keywords
emergency - emotional stress - thyroid storm - thyrotoxicosis
Introduction
Thyroid storm is a rare, life-threatening endocrine emergency characterized by severe
clinical features of thyrotoxicosis.[1] A retrospective study of thyrotoxicosis hospital discharges in the United States
showed 16% of inpatients with thyrotoxicosis were diagnosed with storm.[2] The overall mortality rate of thyroid storm is ranging from 10 to 30% worldwide.[3]
Thyroid storm may be precipitated by an acute event such as thyroid or nonthyroidal
surgery, trauma, infection, an acute iodine load, noncompliance to treatment, or parturition.[3] So, thyroid storm is caused by a precipitating event. Although rare, emotional stress
is reported as an isolated trigger without other precipitating triggers.[4]
In this report, we are reporting a 49-year-old female who was presented with a thyroid
storm from emotional stress after the passing of her mother-in-law.
Case Report
A 49-year-old female presented to Suhar Hospital emergency department with acute severe
shortness of breath. On examination, she was agitated with severe respiratory distress,
and her oxygen saturation was 60% in room air. The blood pressure was 210/110 mm Hg,
pulse rate 150 beats per minute, temperature 39.1°C, and her chest was full of crepitation.
The initial investigations revealed white blood cell count 15.5 × 103/µL, electrocardiography: sinus tachycardia without any ischemic changes, chest X-ray:
bilateral pulmonary congestion, and echocardiography: global hypokinesia with low
ejection fraction (35–40%). A diagnosis of acute pulmonary edema was made. The patient
was intubated immediately and admitted to the intensive care unit, started her on
glyceryl trinitrate infusion and furosemide infusion and kept her under monitoring.
This short presentation of the patient happened within the first 2 days after her
mother-in-law passed away.
The next day, the patient's chest crepitation almost disappeared. It was decided to
stop the glyceryl trinitrate infusion and furosemide infusion, but noted that the
patient still had sinus tachycardia (pulse rate 157 beats per minute), and high-grade
fever (temperature 39.1°C) in addition to agitated state.
While reviewing the patient's records, it was noticed that she was diagnosed with
thyrotoxicosis 9 months ago, with initial free thyroxine (free T4) 64 pmol/L (reference
range, 12-22), free triiodothyronine (free T3) 13 pmol/L, (reference range, 3.1–6.8),
and thyroid-stimulating hormone (TSH) less than 0.005 uIU/mL (reference range, 0.27–4.2)
and managed with carbimazole 10 mg/8 hours and propranolol 40 mg/12 hours, but unfortunately,
the patient was not compliance to treatment and took carbimazole 10 mg once daily.
In view of such a history of thyroid problem, a thyroid panel was sent, and the laboratory
results showed free T4 48.59 pmol/L, free T3 19.64 pmol/L, and TSH less than 0.005
uIU/mL. Such an overall picture of acute pulmonary edema, agitation, severe tachycardia,
high-grade fever with uncontrolled thyrotoxicosis raised the suspicion of thyroid
storm.
According to the Burch and Wartofsky scoring system, a score of 45 or more is highly
suggestive of thyroid storm; thus, the patient met the criteria with a score of 80
([Table 1]).[5]
Table 1
Scoring system to diagnose thyroid storm[a]
|
Thermoregulatory dysfunction, temperature (°F / °C)
|
Point
|
|
99.0–99.9 / 37.2-37.7
|
5
|
|
100.0–100.9 / 37.8–38.2
|
10
|
|
101.0–101.9 / 38.3–38.8
|
15
|
|
102.0–102.9 / 38.9–39.4
|
20[b]
|
|
103.0–103.9 / 39.5–39.9
|
25
|
|
≥ 104.0 / 40
|
30
|
|
Central nervous system dysfunction
|
|
|
Mild (agitation)
|
10[b]
|
|
Moderate (delirium, psychosis, extreme lethargy)
|
20
|
|
Severe (seizures, coma)
|
30
|
|
Gastrointestinal dysfunction
|
|
|
Moderate (diarrhea, nausea/vomiting, abdominal pain)
|
10
|
|
Severe (unexplained jaundice)
|
20
|
|
Cardiovascular dysfunction: tachycardia, beats/min
|
|
|
90–109
|
5
|
|
110–119
|
10
|
|
120–139
|
15
|
|
≥ 140
|
25[b]
|
|
Atrial fibrillation
|
10
|
|
Heart failure
|
|
|
Mild (pedal edema)
|
5
|
|
Moderate (bibasilar rales)
|
10
|
|
Severe (pulmonary edema)
|
15[b]
|
|
Precipitating history
|
|
|
Negative
|
0
|
|
Positive
|
10[b]
|
a A score ≥ 45 is highly suggestive of thyroid storm. A score of 25 to 44 supports
the diagnosis of thyroid storm. A score 25 is unlikely to be thyroid storm. Adapted
from Burch and Wartofsky.5
b Patient's score.
The management started immediately with propylthiouracil 200 mg/4 hours, propranolol
40 mg/6 hours, and hydrocortisone 200 mg as a stat, then 100 mg/6 hours. The Lugol's
iodine was not available to be given. Following 3 days of starting the therapy, there
was significant improvement in the patient's condition; she became afebrile with normal
pulse rate and clear chest. The repeated echocardiography showed improvement in the
ejection fraction to 55%. The patient was extubated at that time. The serial thyroid
panel showed significant improvement after 2 weeks of the therapy with free T4 26.23
pmol/L, free T3 6.49 pmol/L, while the TSH remained suppressed. Further laboratory
results revealed a positive thyrotropin receptor antibody 35.17 IU/L, and thyroid
ultrasound showed multiple small nonsuspicious hyperechoic round nodules, the largest
at the right lobe measured 9 × 5.5mm.
After 3 weeks in the hospital, the patient was discharged. She was on carbimazole
10 mg/12 hours and propranolol 40 mg/12 hours and was given an appointment for thyroid
uptake scintigraphy. Based on the result, we might proceed for radioactive iodine
therapy.
Discussion
The thyroid storm is a life-threatening complication of thyrotoxicosis with high mortality
rate.[6] There are few reported cases in the literature that mentions emotional stress being
a risk factor for thyroid storm.[4] The progression of thyrotoxicosis to thyroid storm cannot be predicted.[7]
According to the Burch and Wartofsky scoring system, the most widely used scoring
system for the diagnosis, the thyroid storm can be manifested with fever, gastrointestinal
or hepatic dysfunction (nausea, vomiting, diarrhea, abdominal pain, and jaundice),
central nervous system dysfunction (agitation, delirium, psychosis, seizure, and coma),
and cardiovascular system dysfunction (tachycardia, arrythmias, and congestive heart
failure).[5] There is another scoring system by the Japan Thyroid Association and Japan Endocrine
Society that also fits the criteria for our patient.[8] Presence of tachycardia and central nervous system dysfunction are the most important
differentiating points between thyrotoxicosis and thyroid storm.[9]
The levels of thyroid hormones do not correlate with the severity of thyroid storm.
Thus, the degree of hyperthyroidism is not a criterion for the diagnosis of thyroid
storm.[6]
In this case report, the previous patient's poorly controlled thyroid status was responsible
for the clinical presentation, and the diagnosis of the thyroid storm, precipitated
by emotional stress was made.
The management includes uses of antithyroid medications, in addition to thioamides,
Lugol's iodine may be given to reduce thyroid hormone production. The use of propranolol
(nonselective beta-adrenergic blockers) is of value to control the tachycardia, and
it is crucial to ensure hemostasis by intravenous fluid hydration. Glucocorticoid
is given to inhibit conversion of thyroxine (T4) to triiodothyronine (T3).[10]
In our case, we used propylthiouracil and we followed the patient by monitoring the
liver function test for hepatotoxicity and complete blood count for agranulocytosis.
In severe cases of thyroid storm that are not responding to aggressive treatment,
the plasma pheresis, charcoal, resin hemoperfusion, or plasma exchange can be used
to remove excessive thyroid hormones from the body.[11] In our case, such treatment options were not required.
Conclusion
In this case, we advise that the clinicians should be aware of the underlying emotional
stress as an important risk for the development of thyroid storm in the absence of
other precipitating factors; also aggressive treatment is very important to limit
the mortality and morbidity related to the thyroid storm.
