A 23-year-old female presented with fever, diarrhea, altered mental status, and seizures. She was diagnosed with thyroid storm based on her symptoms and medical history. Thyroid storm is a rare, life-threatening exacerbation of hyperthyroidism that can affect multiple organ systems. The patient was treated aggressively with antithyroid medications, fluids, steroids, and iodine, and showed marked clinical improvement. Thyroid storm should be considered in hyperthyroid patients presenting with unexplained symptoms affecting multiple systems, as early diagnosis and treatment are essential to reduce the high mortality risk associated with this condition.
A 23-year-old female presented with fever, diarrhea, altered mental status, and seizures. She was diagnosed with thyroid storm based on her symptoms and medical history. Thyroid storm is a rare, life-threatening exacerbation of hyperthyroidism that can affect multiple organ systems. The patient was treated aggressively with antithyroid medications, fluids, steroids, and iodine, and showed marked clinical improvement. Thyroid storm should be considered in hyperthyroid patients presenting with unexplained symptoms affecting multiple systems, as early diagnosis and treatment are essential to reduce the high mortality risk associated with this condition.
A 23-year-old female presented with fever, diarrhea, altered mental status, and seizures. She was diagnosed with thyroid storm based on her symptoms and medical history. Thyroid storm is a rare, life-threatening exacerbation of hyperthyroidism that can affect multiple organ systems. The patient was treated aggressively with antithyroid medications, fluids, steroids, and iodine, and showed marked clinical improvement. Thyroid storm should be considered in hyperthyroid patients presenting with unexplained symptoms affecting multiple systems, as early diagnosis and treatment are essential to reduce the high mortality risk associated with this condition.
A 23-year-old female presented with fever, diarrhea, altered mental status, and seizures. She was diagnosed with thyroid storm based on her symptoms and medical history. Thyroid storm is a rare, life-threatening exacerbation of hyperthyroidism that can affect multiple organ systems. The patient was treated aggressively with antithyroid medications, fluids, steroids, and iodine, and showed marked clinical improvement. Thyroid storm should be considered in hyperthyroid patients presenting with unexplained symptoms affecting multiple systems, as early diagnosis and treatment are essential to reduce the high mortality risk associated with this condition.
Abstract A 23-year-old female patient was hospitalised with complaints of fever, diarrhoea, altered sensorium for 3 days with a rapidly declining mental status. Before admission to the hospital, her relatives gave history of her being restless, markedly irritable with generalised tonic-clonic seizures and a positive history of palpitations. Suspecting the diagnosis of thyroid storm clinically, she was started on aggressive antithyroid treatment following which she showed marked clinical improvement. Thyroid storm is a rare endocrine emergency with increased mortality risk in this otherwise fatal entity. The aim of reporting this case is to make the physicians aware of this fatal medical disease necessitating prompt intervention. A case of thyroid storm presenting with predominant neurological manifestations is being presented here for its rarity. Key words: Thyroid storm, unusual presentation.
Introduction Thyroid storm (accelerated hyperthyroidism) is a rare manifestation of thyrotoxicosis with a wide spectrum of clinical presentations involving multiple systems. It generally occurs in females from the third to the sixth decade of life, especially with Graves disease. It is usually a life-threatening medical emergency and is fatal if left untreated. The classic clinical presentation includes fever, tachycardia, hypertension, tremors, nausea, vomiting, diarrhoea, dehydration, arrhythmias, delirium, and coma1. It usually develops in an undiagnosed hyperthyroid patient who has a major stress or continues without antithyroid treatment in addition to other precipitating factors like surgery, radio-iodine therapy, trauma, acute infection toxaemia of pregnancy, labour, excessive palpation of the thyroid gland in hyperthyroid patients, pulmonary thromboembolism, severe drug reactions, or myocardial infarction, etc 2. Its early recognition and treatment is essential in reducing the morbidity and mortality rate in this potentially fatal disease. Only 1 - 2% of hyperthyroid cases manifest as thyroid storm and the mortality ranges between 20 - 30% despite treatment3.
Case report A 23-year-old unmarried female was brought to the hospital with complaints of fever, diarrhoea, light headedness, altered sensorium for 3 days with a rapidly declining mental status. Before admission, she was reported to be restless, markedly irritable with generalised tonic clonic seizures as well as positive history of palpitations as narrated by relatives. There was no history of previous illness or hospital admission, major surgery, or antipsychotic drugs intake. On
examination, she was febrile (temp 101F), pulse rate 126/
min and regular, BP 110/70 mmHg, respiratory rate 29 breaths/mm, oxygen saturation 98% on 3L. Her pupils were slightly dilated, mucous membranes were moist and the she had an abrasion on the tongue consistent with biting. JVP was normal; there was no lymphadenopathy. Examination of the neck revealed bilateral thyroid enlargement with diffuse toxic goitre with systolic bruit heard over it. She had a stare with a typical anxious look. There were no signs of meningeal irritation. Fundus examination was normal. On neurological examination, she responded to painful stimuli, with brisk deep tendon reflexes and plantar flexor response. CVS examination revealed tachycardia with regular rhythm but no murmurs. Respiratory system and abdominal examination was unremarkable. ECG showed sinus tachycardia. Her laboratory results showed no abnormality of haemogram, blood glucose levels, CSF, serum electrolytes, renal and liver function tests. X-ray chest showed no active disease. CT brain was normal. Blood cultures were negative. EEG revealed bilateral frontal slow waves. Technetium scan of thyroid showed hyperfunctioning gland with diffuse tracer uptake (36% at 20 minutes). The constellation of signs and symptoms suggested that this could be a case of thyroid storm. Based on the diagnostic criteria of Burch and Wartofsky4, she had a total score of 60, which was strongly suggestive of thyroid storm (a score > 25 is suggestive of thyroid storm). The patient was put on antithyroid drugs awaiting thyroid function tests T3, T4, and TSH. She was started on propylthiouracil 400 mg tid and propranolol 40 mg tid, IV fluids, hydrocortisone IV (later changed to oral steroids). Her thyroid profile revealed TSH 0.02 mIU/ml, T4 28 g/dl (N 4 - 14 g/dl); T3 40 ng/dl (N = 0.8 - 2 ng/dl). Thyroid peroxidase autoantibody was negative. Based on
*Professor of Medicine, Government Medical College, Amritsar, Punjab, and Trained Endocrinologist, Department of Endocrinology, PGIMER, Chandigarh; and President, Geriatric Society of India.
clinical presentation and later on confirmed by results,
Lugols iodine 8 drops 8 hourly was given for 3 days. The fever subsided, diarrhoea improved, and agitation decreased. After considerable improvement in her condition in about 8 days time, she was discharged in an euthyroid state, conscious, well oriented, without tremors and fever, and advised to continue on propylthiouracil and propranolol. On follow-up at 3 months, she was carrying our all routine activities with a positive frame of mind.
Discussion Thyroid storm a dramatic exacerbation of existing hyperthyroidism, of sudden onset associated with fever, tachycardia, and CNS symptomatology remains a lifethreatening medical emergency if left untreated. Being a rare endocrine emergency, all clinicians must be aware of its clinical features and treatment so that morbidity and mortality can be avoided. About 1 - 2% of patients with hyperthyroidism progress to thyroid storm and the 100% mortality reported earlier has now come down to 20 - 30% with better recognition and treatment. It might be difficult to distinguish between thyroid storm and infection in thyrotoxic patients as tachycardia and fever might be present in both. On account of an overlapping of the symptoms, precipitating conditions and complications, a clinical diagnosis is not easy and is often made too late.The definitive criteria of thyroid storm laid down by Burch and Wartotsky4 are useful. The triggering factors for thyroid storm include surgery, major stress, noncompliance to antithyroid drugs, infection, radio-iodine, etc2. Treatment of thyroid storm should not be delayed if there is a high index of suspicion, and empirical treatment should be started on clinical grounds awaiting laboratory reports, which was evident in our case5. Urgent thyroid function tests is a confirmatory diagnosis. Hyperglycaemia, hypercalcaemia, leucocytosis may co-exist. Deranged liver functions mainly alkaline phosphatase may occur due to increased osteoblastic activity in response to high bone resorption. Serum thyroid hormone levels would typically show hyperthyroidism, but due to an abrupt rise of thryoid hormone secondary to triggering factors, the patient can no longer adapt to the sudden metabolic stress6. An acute elevation of FT3 or FT4 in thyrotoxic patients may produce acute decompensation. However, no absolute levels of serum T3 or T4 exist above which thyroid storm develops inevitably.7 Earlier, cases of thyroid storm have been well reported where treatment of thyroid storm was started immediately awaiting thyroid function tests8,9. T4 may rarely be normal or even decreasing because of co-existing nonthyroidal illness10. In our case, the patient presented with altered sensorium without signs of raised intracranial tension and focal neurological deficit. Differential diagnosis includes
sympathomimetic toxicity, alcohol withdrawal syndrome, toxic/metabolic encephalopathy, hypertensive encephalopathy, meningitis, etc. But the clinical features of our patient in the form of hypermetabolic state made thyroid storm a definitive diagnosis; and possibly the triggering factor for thyroid storm in this case could be febrile illness. Predominant neurological manifestation in the form of altered mental status and history of tonic clonic generalised seizures was an unusual feature in our case. Treatment of thyroid storm includes correction of severe thyrotoxicosis, precipitating illness, and associated active thyroid eye disease. Patients should be monitored in the intensive care units in the early phase. Diuretics may be given for congestive cardiac failure (CHF). Drugs like thionamides block hormone synthesis; iodine solution blocks the release of thyroid hormone, beta-blockers control adrenergic symptoms, and steroids reduce T4 to T3 conversion. Beta-blockers should be used cautiously in the presence of CHF. Among thionamides, propylthiouracil is preferred over methionazole as it blocks peripheral T4 to T3 conversion. Iodinated radiocontrast iopanoic acid, cholestyramine can also be used. Peritoneal dialysis and plasmaphresis are used to reduce the high levels of circulating T4 and T3 in a thyroid storm5,9,10.
Conclusion Diagnosis may be missed on account of variable presentation. Treatment should never be delayed. A high index of suspicion is required for prompt recognition and effective management of unusual presentation of thyroid storm in order to reduce the morbidity and mortality of this life-threatening medical disorder.
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