VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

06 Thyroid Storm

Messanh Ameduite DO, CST; Diana Duong, DO, MS; Kimberly Bird, MD Corresponding author:

SOVAH Health Internal Medicine Residency Program

not require supplemental oxygen at baseline. Allergies: No known drug allergies. Pertinent ROS: Constitutional: fatigue, malaise. GI: Nausea, Vomiting. Cardiovascular: chest pain, palpitations. Pertinent Physical Examination: BP 148/65, HR 120, RR 20, T 98.3°F, SpO2 97% on room air. Heart: tachycardic, regular S1 and S2, no murmur. Extremities: +1 pitting edema in bilateral lower extremities. Pertinent Labs: hemoglobin 10.6, potassium 5.3, carbon dioxide 15, anion gap 18, BUN 43, creatinine 1.58, glucose 353, AST 140, ALT 141, high sensitivity troponin 244, BNP 245, lipase 48, TSH < 0.01, free T4 > 8, beta-hydroxybutyrate 7. Clinical Course: Thyroid storm can be clinically diagnosed using the Burch-Wartofsky Point scale. This patient scored 50 (highly suggestive of thyroid storm) with a total T3 elevated at 392, free T3 of 183, thyroglobulin antibody < 1.0, and thyroid peroxidase antibody elevated at 273. The patient was initiated on an esmolol drip, methimazole 20mg q4h, propranolol 40mg q6h, cholestyramine 4mg PO tid,

potassium iodide five drops q6h PO given 1 hour after methimazole, hydrocortisone 100mg IV q8h. The neck ultrasound showed a right-sided nodule 0.8 mm TI-RADS1 and hypervascularity, indicating thyroid storm. The patient was found to have Graves’ disease concomitant with a thyroid nodule. Total T3 and free T3 trended down and normalized after five days of therapy. Hydrocortisone was titrated down to 100mg daily. The patient was discharged with propranolol and methimazole with a plan to follow up with endocrinology for radioiodine therapy. Comment: Thyroid storm is a very rare complication of hyperthyroidism involving 5-7 per 1 million people in the United States Conclusion: Thyroid storm is a life-threatening condition if untreated. Management requires admission to the ICU and multifactorial drug therapy, including glucocorticoids, beta-blockers, thionamides, and iodide solution, to ameliorate thyrotoxicosis and its effect on multiple organ systems.

Context: Thyroid storm is a life-threatening condition and an infrequent complication of hyperthyroidism, Graves’ disease, and toxic thyroid adenoma. Case Report: 52-year-old female with complaints of abdominal pain associated with nausea and vomiting. At presentation, the patient was agitated and mildly confused. She was found to have complete suppression of her TSH and a severely elevated free T4. Past Medical History: Insulin-dependent diabetes mellitus, CHF with unknown EF, paroxysmal atrial fibrillation, and thyroid disorder. Family History: Hypertension and diabetes. Past Surgery History: Thyroid biopsy performed four months prior to presentation. Outpatient Medication: atorvastatin 40mg po qhs, insulin aspart novoLog sliding scale, insulin glargine 26 units SC qhs, metformin 1000mg BID, tramadol 50mg po qid prn. Social History: The patient lives at home with her sister and performs ADL independently. She does


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