Thyroid Crisis and

Thyroid Cardiac
Disease with
Acute Hepatitis
Complication
A Case Report
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

Patient Identity

● Name : Mr.s YS
● Age : 42 years old
● Occupation : civil officer
● Address :
● Ethnicity : Minahasa
● Religion :
● Room : CVCU
● Admission date : 4 February 2020
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Medical History

Admitted to RSUP
4 year prior to 1 week prior to 1 day prior to
admission (2017) Several months
Prof. dr. RD Kandou
admission admission
• Diagnosed with prior to admisson • Painless, swollen feet • Shortness of breath at rest
4 February 2020
tyroid disease • Dyspnea on effort • Nausea and vomiting • Shortness of breath
• On routine • Palpitation on rest • Vomits 3 time with volume a • Nausea and vomitting
medication but glass with fluid and food
stopped at 2019 residue

Denied :
Hypertension
Diabetes mellitus
Food and medication allergy
No family history of similar disease
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication
Physical Examination
● General State : Severely ill ● Eyes : normal conjunctive,
● Consciousness : Compos Mentis isochor pupil
● BP : 109/81mmHg ● Mouth : no coated tongue
● HR : 140 times/min, irregular ● Neck : no lymph node enlargement, no
● RR : 32 times / min palpable mass, no tracheal deviation, no
● T : 36.4oc increased jugular vein pressure
● O2 Sat : 94%
● Weight : 55 kg
● Height : 155 cm
● BMI : 15,62 kg/m2
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication
Lungs
Insp : Symmetrical at static and
dynamic condition
Palp : Stem fremitus R = L
Perc : Sonor R = L
Ausc : Vesicular breath sound
(+/+), rhonchi (+/+) in
bilateral lung bases,
wheezing (-/-)
Heart
Insp : IC not visible
Palp : IC palpable at ICS V left midclavicular line,
thrill (-), heave (-)
Perc : Right border at right sternal line
Left border at ICS V left midclavicular line
Ausc : SI-SII normal, regular, murmur (-),
gallop (-), heart rate 140 bpm
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

Abdomen Extremities

Insp : flat Normal skin color

Ausc : bowel sound (+) 10 times/min
Pitting edema (+/+)
Palp : supple, suprapubic tenderness
Warm on palpation
Perc : tympanic
 Laboratory Test
Hemoglobin 13,0 gr/dL MCH 26,7 pg
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

Hematocrit 40,1%
MCV 82,6 fL
Leukocytes 6.900 mg/dL
Thrombocytes 173.000 mg/dL MCHC 32,4 g/dL
Erythrocytes 4,86 x 106/mm3
Blood glucose 104 mg/dL
Basophils 0%
eosinophils 0% SGOT / SGPT 181 / 265 U/L
Band neutrophils 4%
Ureum 27 mg/dL
Segment neutrophils 49%
Lymphocytes 39% Creatinine 0,4 mg/dL
Monocytes 8% Albumin 3,88 g/dL
Na+ 133 mEq/L TSHS <0.005 µIU/mL
K+ 3,97 mEq/L fT4 7.89 mg/dL
Cl- 93,6 mEq/L Troponin T < 40 ng/L
Mg 1,79 mg/dL PT / APTT / INR 23.6 / 33.9 / 2.30 second
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Thorax X-ray

Emergency echocardiography : EF 20%, moderate-to-severe mitral regurgitation, moderate tricuspid

regurgitation
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

Patient’s ECG
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication
Abdominal US
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication
Working Diagnosis
● Acute decompensated heart failure (ADHF) FC III-IV ec thyroid
cardiac disease
● Thyroid crisis
● Dyspepsia
● Acute hepatitis

Burch Wartosky score : Japanese Thyroid Association :

• Hepatic-gastrointestinal dysfunction 20 TS1 with alternate combination
• Cardiovaskuler 55
(HR ≥ 140, severe CHF, precipitating factor)
Total score 75 (suggestive thyroid storm)
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

Therapy
● O2 4 lpm via nasal cannule
● Furosemide 60 mg IV every 24 hr
● Spironolactone 25 mg 1-1-0 oral
● Alerten 1 caps oral every 12 hr
● Digoxin 0,25mg IV if HR ≥ 130 bpm
● Lanzoprazole 30mg oral every 12 hr
● Curcuma 1 tab oral every 8 hr
● Endocrine consult : infusion of dextrose 5% 500cc every 24 hr,
thiamazole 20mg oral every 4 hr, dexamethasone 2 mg IV every 6 hr,
lugol 8 drops every 6 hr 1 hr after taking thiamazole
● Admit to CVCU
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 3 (6 Feb 2020)
Subjective Objective Assessment Planning

Improvement on GS : moderately ill, • Thyroid crisis improved Thiamazole changed to

shortness of breath, Consciousness: CM, • ADHF on CHF FC III- 20mg every 6 hr
nausea and BP 108/71mmHg, IV ec thyroid cardiac
vomiting (-) HR 88x/min disease improved Lugol stopped
RR 18x/min, T 36.6oc
O2 98% • Dyspepsia Dexamethasone changed to
• Acute hepatitis 2mg IV every 8 hr
• hyponatremia
Burch Wartofsky score : 20

Na 128 mEq/L
K 4,41 mEq/L
Cl 88,8 mEq/L
Mg 2.15 mg/dL
Albumin 3.55 g/dL
Ca 8.16 mg/dL
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 5 (8 Feb 2020)
Subjective Objective Assessment Planning
Improvement on GS : moderately ill, • Thyroid crisis improved Thiamazole stopped
shortness of breath Consciousness: CM, • ADHF on CHF FC III-
BP 108/71mmHg, IV ec thyroid cardiac Furosemide changed to
HR 96x/min disease improved 20mg 1-1-0 IV
RR 18x/min, T 36.6oc
O2 98% • Dyspepsia (+) ramipril 1.25mg oral
• Drug induced acute every 24 hr
Burch Wartofsky score : 10 hepatitis
• thrombocytopenia
Hb 14 g/dL • hyponatremia
Ht 44.7%
Erythrocytes 5.49 x 106/mm3
Leucocytes 6400/mm3
Thrombocytes 133,000/mm 3
MCH 25.6 pg
MCV 81.3 fl
MCHC 31.4 g/dL
SGOT/ SGPT 153/694 U/L
Ureum 54 mg/dL
Creatinine 0.6 mg/dL
Na 131 mEq/L
K 3,91 mEq/L
Cl 87.1 mEq/L
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 8 (11 Feb 2020)
Subjective Objective Assessment Planning

Improvement on GS : moderately ill, • Thyroid crisis improved Transfer to ward

shortness of breath Consciousness: CM, • ADHF on CHF FC III-
BP 99/68mmHg, IV ec thyroid cardiac Dexamethasone changed to
HR 86x/min disease improved 2mg IV every 12 hr
RR 22x/min, T 36.5oc
O2 98% • Dyspepsia
• Drug induced acute
Burch Wartofsky score : 10 hepatitis
• thrombocytopenia
• hyponatremia
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 9 (12 Feb 2020)
Subjective Objective Assessment Planning
Improvement on GS : moderately ill, • Thyroid crisis improved Continue pharmacological
shortness of breath Consciousness: CM, • ADHF on CHF FC III- therapy
BP 95/60mmHg, IV ec thyroid cardiac
HR 85x/min disease improved
RR 20x/min, T 36.4oc
O2 98% • Dyspepsia
• Drug induced acute
Burch Wartofsky score : 10 hepatitis
• Thrombocytopenia
Hb 15.9 g/dL improved
Ht 45.2% • hyponatremia
Erythrocytes 6.05 x 106/mm3
Leucocytes 12.200/mm3
Thrombocytes 195,000/mm3
Diff count : 0/0/0/86/6/8
MCH 26.3 pg
MCV 74.7 fl
MCHC 35.2 g/dL
Na 132 mEq/L
K 4.01 mEq/L
Cl 88.4 mEq/L
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 12 (15 Feb 2020)
Subjective Objective
Painful urination, GS : moderately ill,
fever (+) Consciousness: CM,
Shortness of breath BP 93/60mmHg,
(-) HR 88x/min,RR 20x/min, T 38oc
O2 98%
Burch Wartofsky score : 20
Hb 16.6 g/dL
Ht 51%
Erythrocytes 6.57 x 10 /mm
6 hepatitis
Assessment Planning
• Thyroid crisis improved Add ceftriaxone 2 gr IV
• ADHF on CHF FC III- every 24 hr
IV ec thyroid cardiac
disease improved Dexamethasone changed to
2 mg IV every 24 hr
• Suspct urinary tract
infection Plan : urinalysis
• Dyspepsia
• Drug induced acute
3

Leucocytes 24.900/mm 3

Thrombocytes 63,000/mm 3• Thrombocytopenia

Diff count : 0/0/1/90/5/4
MCH 25.2 pg improved
MCV 77.6 fl
MCHC 32.5 g/dL
• hyponatremia
Ureum 56 mg/dL
Creatinine 0.5 mg/dL
Na 127 mEq/L
K 5.08 mEq/L
Cl 82.3 mEq/L
Total bilirubin 5.45 mg/dL
Direct bilirubin 3.33 mg/dL
Gamma Gt 104 U/L
SGOT/SGPT 32/78
Alkaline phosphatase 108 U/L
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 13 (16 Feb 2020)
Subjective Objective Assessment Planning
Painful urination, GS : moderately ill, • Thyroid crisis improved Continue pharmacological
fever (+) Consciousness: CM, • ADHF on CHF FC III- therapy and re-evaluate
Shortness of breath BP 100/60mmHg, IV ec thyroid cardiac liver transaminase test
(-) HR 96x/min,RR 20x/min, T disease improved
37.5oc,O2 98%
• Suspct urinary tract
Burch Wartofsky score : 20
infection
Urinalysis :
Macroscopic : yellow, cloudy
• Dyspepsia
Microscopic : • Drug induced acute
Erythrocyte 15-16/lpf
Leucocytes 8-10/lpf hepatitis
Epitels 3-5/hpf
No bacterias, yeast and amoeba found
• Thrombocytopenia
Gravity 1005 improved
pH 7
Leucocyte +3 • hyponatremia
Nitrites (-)
Protein +1
Glucose (-)
Ketones (-)
Urobilinogen +1
Bilirubin +1
Blood/erythrocytes +4
Cylinder (-)
Crystal (-)
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 14 (17 Feb 2020)
Subjective Objective Assessment Planning
Painful urination, GS : moderately ill, • Thyroid crisis improved Furosemide change to
fever improved Consciousness: CM, • ADHF on CHF FC III- 20mg 1-0-0 IV
Shortness of breath BP 100/68mmHg, IV ec thyroid cardiac
(-) HR 92x/min,RR 20x/min, T disease improved Ramipril changed to 1.25
36.2oc, O2 98% mg oral every 12 hr
• Suspct urinary tract
infection
Burch Wartofsky score : 10
• Dyspepsia
Hb 17.3 g/dL
Ht 53.7%
• Drug induced acute
Erythrocytes 6.88 x 106/mm3 hepatitis
Leucocytes 11.100/mm3
Thrombocytes 74,000/mm3 • Thrombocytopenia
MCH 25.2 pg
MCV 78.1 fl improved
MCHC 32.2 g/dL
TSHS < 0.005µIU/mL
• hyponatremia
fT4 3.34 mg/dL
Creatinine 0.5 mg/dL
Na 119 mEq/L
K 5.31mEq/L
Cl 78.3 mEq/L
Total bilirubin 5.24 mg/dL
Direct bilirubin 3.13 mg/dL
Gamma Gt 94 U/L
SGOT/SGPT 26/41
Alkaline phosphatase 102 U/L
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 15 (18 Feb 2020)
Subjective Objective Assessment Planning
Painful urination, GS : moderately ill, • Thyroid crisis improved Continue pharmacological
fever, shortness of Consciousness: CM, • ADHF on CHF FC III- therapy
breath (-) BP 90/60mmHg, IV ec thyroid cardiac
HR 85x/min,RR 20x/min, T disease improved
36.3oc, O2 98%
• Suspct urinary tract
infection
Burch Wartofsky score : 10
• Dyspepsia
Echocardiography : • Drug induced acute
LVH, LA, LV, RA, RV dilatation (-)
Decreased global LV systolic function EF
hepatitis
18% • Thrombocytopenia
Severe hypokinetic global improved
Restrictive diastolic dysfunction
Trivial AR • hyponatremia
Moderate-to-severe MR
High probability of PH
Decreased RV contractility
Minimal PE 0.5 mm in posterior LV and
superior RA
IVC 1.9 cm, collapsibility 25-50%
RAP/CVP 10-15
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Follow up day 16 (19 Feb 2020)
Subjective Objective Assessment Planning

Painful urination, GS : moderately ill, • Thyroid crisis improved Plan to discharge with
fever, shortness of Consciousness: CM, • ADHF on CHF FC III- medication :
breath (-) BP 95/71mmHg, IV ec thyroid cardiac PTU 3x200mg PO
HR 95x/min,RR 20x/min, T disease improved Spironolactone 25mg 1-1-0
36.3oc, O2 98% PO
• Suspect urinary tract Alerten 1x1 cap PO
infection Lanzoprazole 2x30mg PO
Burch Wartofsky score : 10
• Dyspepsia Furosemide 20mg 1-0-0 PO
• Drug induced acute Ramipril 1x1.25 mg PO
hepatitis
• Thrombocytopenia
improved
• hyponatremia
 Discussion
• Thyroid crisis is a rare condition that reflect extreme physiologic state of thyrotoxicosis of any etiology, with
mortality rate up to 10-20% and mostly found in Graves disease
• Hyperthyroidism in woman 0.5-2% and incidence is higher in female than male
• Mirna et al : majority of thyrotoxicosis age from 30-69 y.o with peak 50-59 y.o
• Thyroid crisis is precipitated by untreated hyperthyroidism and other acute conditions (trauma, surgery, infection,
CV events)
• Our patient is 42 y.o female with history of hyperthyroidism since 2017

T4 will be converted to Precipitating factors in thyroid

Excess of thyroid hormone T3, binds to thyroid
-> circulating T4 and T3 hormone receptor to
will be uptaked by cell
induced gene activation
and transcription
In hypophysis, thyroid
crisis will release thyroid
hormone negative
hormone from its receptors and
feedback on TSH gene
increase peripheral thyroid
transcription
receptor sensitivity
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

Symptoms :
● Fever
● Arrythmia, atrial fibrillation, congestive heart failure
● Central nervous system manifestation
● GI and hepatic manifestation : nausea, vomiting, jaundice, diarrhea,
increased liver transaminase

Hepatic failure in thyroid crisis can be caused by increased intertinal peristalsis,

increased liver metabolism in relative to decreased hepatic blood flow, liver
congestion from right heart failure and hepatotoxicity of several antithyroid
regiment

Hyperthyroid also increase reticuloendothelial system which shortens platelet

life span thus causing thrombocytopenia
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Burch-Watorsky scoring system
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Japanese Thyroid Association criteria
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication Japanese Thyroid Association criteria
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

T3
● Effect on cardiovascular system:
- increased contractility and rate of systolic contraction and diastolic relaxation
- decreased vascular resistance which activates RAS
- effects are mediated by thyroid receptor α and β, with TRα predominantly found in heart
- increased erythropoiesis -> increased total blood volume and cardiac output -> LVH

● Liver failure
- increased oxygen consumption due to increased metabolism -> relative perivenular hypoxia
-> oxidative stress
● Disrupt mitochondrial activity and activation of hepatocyte apopotosis
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication
Therapy

Aim Supportive therapy, inhibition of new hormone systhesis, inhibition of hormone

release, blockade peripheral β adrenergic receptor, prevent convertion from
T4 to T3, indetification and management of precipitating factors

Medication • Methimazole 20-30mg every 4 hr

• PTU 300mg every 4-6 hr
• Propanolol 60-80mg every 6 hr or 1-5mg every 6 hr IV (contraindicated in ADHF)
• Hydrocortisone 100-500mg IV every 12 hr or dexamethasone 2 mg every 6 hr
• Low blood glucose can be managed by infusion of dextrose 5 or 10%

Heart failure management • Loop diuretics, can be combine with spironolactone

• ACE inhibitor to surpress neurohormonal activation in heart failure caused by LV
dysfunction
• Digoxin can be used in symptomatic patient with systolic LV dysfunction and atrial
fibrillation
 Conclusion
Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

● It has been reported cases of thyroid crisis and thyroid cardiac disease with
acute hepatitis as complication in 42 years old female. Diagnosis is confirmed
by anamnesis, physical examination, and supportive investigation. Patient
had Burch-wartofsky 75 with JTA criteria of TS2
● The treatment given to these patients includes nonpharmacological and
pharmacological.
● Prognosis :
ad vitam is dubia
ad function is dubia
ad sanasionam dubia
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Thyroid Crisis and Thyroid Cardiac Disease with Acute Hepatitis Complication

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