Thyroid Storm: Karthik Balachandran Karthik2k2

Thyroid Storm
Karthik Balachandran
karthik2k2
Case 1
Case 1
• 56 year female
• k/c/o hyperthyroidism, diagnosed as Graves disease elsewhere when she presented
with weight loss, palpitations, tremors
• Lost follow up after lockdown
• Developed fever and sorethroat
• Tested twice for COVID19- negative
• Breast cancer survivor, operated 7 years back
• No cardiac history
Karthik Thyroid Storm December 6, 2020 3 / 46

Course …
• Admitted to the ICU

• Developed breathlessness and tachycardia
• Found to have an unimpressive goiter
• No jaundice

Relevant Labs …
Parameter Value
Sodium 134 mEq/L

Potassium 4 mEq/L
FT3 9.2 pg/ml
FT4 4.05 ng/dl
TSH <0.01 mIU/L
Hb 10.1 gm/dl
Total Count 1400
ANC 560
ALT 45 IU/L

Could it be storm?
Clinical points
Suspect a storm in any sick thyroid patient, even if you have never seen a storm before
There is no clean cut off of T3/T4/TSH to differentiate ’routine’ thyrotoxicosis from thyroid
storm

Thyroid storm
Thyrotoxicosis Systemic Trigger

decompensation

What is this?
Storm Agranulocytosis

How to diagnose?
Burch Wartofsky score

• Thermoregulatory dysfunction
• Cardiovascular manifestations
• Tachycardia
• Atrial fibrillation
• Congestive heart failure
• Gastro intestinal / hepatic dysfunction
• CNS dysfunction
• Precipitating history
Total score: ≥ 45 - thyroid storm, 25–44: impending thyroid storm, <25: unlikely thyroid
storm

How common is the storm?1
1
< 1 % of patients with thyrotoxicosis develop storm
Double trouble
Storm Agranulocytosis

Returning to the drug records
Clinical points
What drug was the patient taking and what dose?
Both PTU and Methimazole can cause agranulocytosis, but PTU in addition has a much
higher risk of hepatotoxicity and ANCA+ vasculitis

Returning to the drug records
Clinical points
What drug was the patient taking and what dose?
Both PTU and Methimazole can cause agranulocytosis, but PTU in addition has a much
higher risk of hepatotoxicity and ANCA+ vasculitis
The patient was taking carbimazole 10 mg 1-1-1

Treatment options
Principles of treatment
1 Stop production of thyroid hormone
2 Stop further release of thyroid hormone
3 Stop action of already released thyroid hormone
4 Take care of systemic actions that have already happened

Drug menu
Drug Principle
MMI/Carbimazole Stop production

PTU Stop production
Potassium perchlorate Stop production
Iodine(SSKI / Lugol’s) Stop release
Lithium Stop release
Cholestyramine Stop action
β blockers Stop action
Steroids Stop action

Choices
Clinical points
When one thionamide causes serious toxicity (vascular/hepatic/hematologic), it can’t be
replaced by another thionamide
Perchlorate has two problems - availability & aplastic anemia
Lithium + Iodine ≯ Lithium or Iodine

Non pharmacologic options
• Plasmapheresis
• Charcoal and resin hemoperfusion

Plasmapheresis
• Large volume plasmapheresis

• Removes TBG with bound hormone & antibodies
• Removes ≈ 20 % of the T4 pool & even less of the T3 pool during the procedure
• Effect is transient (24 to 48 hours)

Back to our patient …
Problems
• Impending storm
• Agranulocytosis
• ? Sepsis 2
2
Blood culture was negative,but can’t rule out systemic infection
Options
Pharmacologic options for thyroid control in our patient

• Lithium
• Cholestyramine
• Steroids
• β blockers
• Supportive care

Supportive care is extremely important
Supportive care
• Antipyretics - paracetamol, external cooling

• Check for access - iv, oral / rectal
• Broad spectrum antibiotics
• Fluid management
• Glycogen depletion - prefer Dextrose containing fluids
• May be thiamine deficient - add Thiamine to prevent Wernicke’s encephalopathy,
especially in alcoholics
Caution
Salicylates should not be given - they ↓ protein binding & ↑ freehormone levels

Course …
• Stopped methimazole
• Lithium 300 mg Q 8 hrly
• Dexamethasone 2 mg iv Q 8 hrly
• Propranolol 40 mg Q 6 hrly 3
• Meropenem + levofloxacin
• Filgrastim (G-CSF) - 75 µg / day
Plan : Defitive treatment (surgery or radioiodine ablation after stabilization
3
T → T3 conversion blockade happens at high doses >160 mg/dl
Day 5 …
• Fever improved
• Counts increased to 8000/µL
• Beta blockers tapered
• Shifted to HDU

Day 6 …

Mimics

What went wrong?
• G-CSF induced rapid expansion of cell pool

What went wrong?

• Hypokalemia

What went wrong?

• Hypokalemia
• Tapering of beta blockers

What went wrong?

• Hypokalemia
• Tapering of beta blockers
• High levels of thyroid hormone

Course
• Electrolyte abnormalities corrected

• Managed with cardiologist
• Surgery vs radioiodine ablation choice - decided on radioiodine ablation
• 3 month follow up - the patient is better

Learning point
Just like any other medical emergency be prepared for second order complications
in thyroid storm

Case 2
History
• 30 year male, weight loss & hyperdefecation for several weeks

• Symptoms deteriorated - confusion
• Brought to emergency
• Past hx - methimazole 7 months back, underwent wisdom tooth extraction 4 weeks
back
• Younger brother has type 1 diabetes

Examination
Pulse 140 bpm

Temp 101 ◦ F
Resp 25 breaths/min
Eye Graves ophthalmopathy

Labs
Parameter Value
TSH <0.001 mIU/L

FT4 8.1 ng/dl
ALT 80 U/L
AST 78 U/L
Sodium 137 mEq/L
Potassium 4.5 mEq/L

Diagnosis
Burch Wartofsky score

• Thermoregulatory dysfunction
• Cardiovascular manifestations
• Tachycardia
• Atrial fibrillation
• Congestive heart failure
• Gastro intestinal / hepatic dysfunction
• CNS dysfunction
• Precipitating history
Total Score: 80

Thyroid storm
Thyrotoxicosis Systemic Trigger

decompensation

Learning points
Young patients can develop storm too
Stopping drugs is a common precipitant
CNS symptoms are an easy clue

Case 3
History
• 60 year male with fever, weight loss, fatigue

• h/o CLL - received Rx with bendamustine + rituximab
• Admitted to ICU with febrile neutropenia

Examination
Temp 102.5 ◦ F
Pulse 132 bpm
PE Left sided neck swelling ,tender on palpation

Labs
Parameter Day 1
TSH 0.02
FT4 6 ng/dl
TC 66,900/µL
Monocyte 98%

Imaging
• CT - lymphomatous nodules in lung, spleen, liver & kidney

• Thyroid gland normal

Labs
Parameter Day 1 Day 3
TSH 0.02 -
FT4 6 ng/dl >8 ng/dl
TC 66,900/µL -

Labs
Parameter Day 1 Day 3
TSH 0.02 -
FT4 6 ng/dl >8 ng/dl
TC 66,900/µL -
Poor response to methimazole

Imaging
• CT - progression of lymphomatous lesions

• Infiltration of thyroid gland
• Plasmapheresis planned, but patient succumbed

Learning points
All neutropenia in patients on ATDs are not due to ATD
Cause of thyrotoxicosis matters
Time is life, like any other emergency

Summary-Diagnosis
Thyrotoxicosis Systemic feature Trigger
Search for the cause Burch Wartofsky score Search

Doubt → Rx Neutralize

Summary-Diagnosis
Thyrotoxicosis Systemic feature Trigger
Search for the cause Burch Wartofsky score Search

Doubt → Rx Neutralize
Key
Suspicion is the most important step

Summary-Treatment
Principle Complications Definitive Rx
øProduction : Supportive care Ablation

MMI/PTU Anticipation Surgery
øRelease : Li / Iodine
øAction : Steroid/β
blocker

Thank you !
This presentation can be downloaded from

www.medicalruminations.wordpress.com
cbna

Thyroid Storm: Karthik Balachandran Karthik2k2

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Thyroid Storm: Karthik Balachandran Karthik2k2

Uploaded by

Copyright:

Available Formats

Thyroid Storm

Karthik Thyroid Storm December 6, 2020 3 / 46

• Admitted to the ICU

Karthik Thyroid Storm December 6, 2020 4 / 46

Sodium 134 mEq/L

Karthik Thyroid Storm December 6, 2020 5 / 46

Karthik Thyroid Storm December 6, 2020 6 / 46

Thyrotoxicosis Systemic Trigger

Karthik Thyroid Storm December 6, 2020 7 / 46

Karthik Thyroid Storm December 6, 2020 8 / 46

Burch Wartofsky score

Karthik Thyroid Storm December 6, 2020 9 / 46

Karthik Thyroid Storm December 6, 2020 11 / 46

Karthik Thyroid Storm December 6, 2020 12 / 46

The patient was taking carbimazole 10 mg 1-1-1

Karthik Thyroid Storm December 6, 2020 12 / 46

Karthik Thyroid Storm December 6, 2020 13 / 46

MMI/Carbimazole Stop production

Karthik Thyroid Storm December 6, 2020 14 / 46

Perchlorate has two problems - availability & aplastic anemia

Lithium + Iodine ≯ Lithium or Iodine

Karthik Thyroid Storm December 6, 2020 15 / 46

Karthik Thyroid Storm December 6, 2020 16 / 46

• Large volume plasmapheresis

Karthik Thyroid Storm December 6, 2020 17 / 46

Pharmacologic options for thyroid control in our patient

Karthik Thyroid Storm December 6, 2020 19 / 46

• Antipyretics - paracetamol, external cooling

Karthik Thyroid Storm December 6, 2020 21 / 46

Plan : Deﬁtive treatment (surgery or radioiodine ablation after stabilization

Karthik Thyroid Storm December 6, 2020 23 / 46

Karthik Thyroid Storm December 6, 2020 24 / 46

Karthik Thyroid Storm December 6, 2020 25 / 46

• G-CSF induced rapid expansion of cell pool

Karthik Thyroid Storm December 6, 2020 26 / 46

• G-CSF induced rapid expansion of cell pool

Karthik Thyroid Storm December 6, 2020 26 / 46

• G-CSF induced rapid expansion of cell pool

Karthik Thyroid Storm December 6, 2020 26 / 46

• G-CSF induced rapid expansion of cell pool

Karthik Thyroid Storm December 6, 2020 26 / 46

• Electrolyte abnormalities corrected

Karthik Thyroid Storm December 6, 2020 27 / 46

Karthik Thyroid Storm December 6, 2020 28 / 46

• 30 year male, weight loss & hyperdefecation for several weeks

Karthik Thyroid Storm December 6, 2020 30 / 46

Pulse 140 bpm

Karthik Thyroid Storm December 6, 2020 31 / 46

TSH <0.001 mIU/L

Karthik Thyroid Storm December 6, 2020 32 / 46

Burch Wartofsky score

Karthik Thyroid Storm December 6, 2020 33 / 46

Thyrotoxicosis Systemic Trigger

Karthik Thyroid Storm December 6, 2020 34 / 46

Young patients can develop storm too

Stopping drugs is a common precipitant

CNS symptoms are an easy clue

Karthik Thyroid Storm December 6, 2020 35 / 46

• 60 year male with fever, weight loss, fatigue

Karthik Thyroid Storm December 6, 2020 37 / 46

Karthik Thyroid Storm December 6, 2020 38 / 46

Karthik Thyroid Storm December 6, 2020 39 / 46