Endocrine Interesting Case Sethanant Sethakarun, MD

Aug 21, 2013

• Patient Profile:

หญงไทยค อาย 44 ป อาชพแมบาน

ภมล าเนา อ าเภอปกธงชย จงหวดนครราชสมา

• CC: เหนอยมากขน 3 วน

•Present illness

Underlying disease thyrotoxicosis วนจฉยประมาณ 10 ปกอน กนยาไมสม าเสมอ ลาสดขาดยา 4 เดอน

- 1 เดอนกอนมารพ. เรมเหนอยงาย ท างานบานแลวเหนอยมากขน นอนราบได ไมมตนมาเหนอยหอบกลางคน ไมเจบแนนหนาอก ใจสนเปนๆหายๆ ขาไมบวม ปสสาวะปกต คอไมโต

กนเทาๆเดม น าหนกลด 6 กก.ในเวลา 2 เดอน

• 3 วนกอนมารพ. เหนอยมากขนกวาเดม เดนระยะสนๆแลวเหนอย ใจสน ขาบวม 2 ขาง ปสสาวะปกต แนนทองเปนๆหายๆ ไมมคลนไสอาเจยน ไมมตวเหลองตาเหลอง ไมมไข

ถายเหลวเปนน า 4-5 ครง ไมมมกเลอดปน ไมไอ ไมเจบคอหอบเหนอย จงไปรพ.ปกธงชย แลวสงตอมาทรพ.มหาราชนครราชสมา

•Past Hx.:- ปฏเสธแพยาแพอาหาร

- ปฏเสธดมเหลาสบบหร

- ปฏเสธการใชยาหมอ,ยาตม,ยาลกกลอน,ยาสมนไพร

•Current Medication:

MMI(5) 1.5 tab oral OD pc

Atenolol(100) 0.5 tab oral OD pc

Physical Examination

• V/S-BP 160/80 mmHg PR 146 bpm(totally irregular)

BT 37.3 °C RR 24 times/min

• General appearance- A middle-aged Thai woman,

good consciousness, alert

• HEENT- mild pale conjunctivae, anicteric sclerae,

proptosis, lid retraction, no lid lag, no limit ROM,

no lymph node enlargement

• Thyroid gland- diffusely enlarged ~ 30 gm, no

bruit, firm consistency, smooth surface, movable

CVS- neck vein engorged, totally irregular pulse rate

146 bpm, PMI at 6th ICS anterior axillary line, no

heave, no thrill, variable S1, no murmur

Lung- fine crepitation both lower lungs

Abdomen- flat shape, normoactive bowel sound, soft,

not tender, no hepatosplenomegaly, no abnormal

mass

Ext.- warm and moist skin, onycholysis at ring

finger of left hand, fine tremor both hands,

pitting edema 1+ both legs, no thyroid acrpachy,

no palmar erythema, no pretibial myxedema

Neuro- good conscious, pupil 3 mm RTLBE, full

EOM, no facial palsy, normal muscle tone, motor

grade 5 all, DTR 2+ all, BKK absent bilateral

Problem Lists

1. Suspected thyroid storm

2. U/D Thyrotoxicosis with poor compliance

3. Congestive heart failure

4. Atrial fibrillation with rapid ventricular response

Investigations

TFT (แรกรบ)

FT3 13.4 pg/ml (2.39-6.79)

FT4 5.5 ng/dl (0.6-1.6)

TSH 0.235 uIU/ml (0.3-5.0)

CBC: Hb 9.7 Hct 30.6% MCV 72.4

Plt 158,000 WBC 5,500 (N 76 L 7 M 17)

Na 138.3 K 3.52 Cl 108.2 HCO3 26, BUN/Cr: 6.9/0.43

• EKG 12 leads

• CXR

• Echocardiography:

good LV systolic contraction, EF 71%

normal wall motion

No significant valvular lesion

Not seen thrombus

Hyperthyroid cardiomyopathy with AF

Initial management

• PTU 6 tabs oral stat then 4 tabs oral q 4 hr

• Lugol's solution 10 drops oral q 6 hr (after PTU 2 hr)

• Dexamethasone 2 mg IV q 6 hr

• Digoxin 0.25 mg IV

• On O2 canular 3 LPM

Thyroid Storm

Thyroid Storm

• Decompensated thyrotoxicosis

• Life-threatening medical condition

• Mortality 20-30%

Thyroid Storm

• Underlying cause of thyrotoxicosis

Graves' disease

Solitary toxic adenoma

Toxic multinodular goiter

Precipitating Factors

• Stress: infection, surgery, trauma, MI, DKA, in labor

• Discontinuation of antithyroid drugs

• Excessive administration of iodine or thyroid

hormone: I131, pseudoepedrine, salicylate use

Signs and Symptoms •Hyperthyroidism with …..

High fever 39-40 C

CVS dysfunction: heart failure, tachyarrhythmia

GI-hepatic dysfunction: diarrhea, nausea/vomiting,

abdominal pain, unexplained jaundice

CNS: agitation, psychosis, seizure, coma

** Apathetic hyperthyroidism in aging (only

neuro symptom or cachexia)**

Burch and Wartofsky Score

• >45 : highly suggestive of thyroid storm

• 25-44 : impending thyroid storm

• <25 : unlikely thyroid storm

Burch and Wartofsky Score

Burch, H. B. und L. Wartofsky (1993). "Life-Threatening Thyrotoxicosis. Thyrotoxic storm. " Endocrinology and Metabolism Clinics of North America 22(2): 263-77.

Burch and Wartofsky Score

Burch, H. B. und L. Wartofsky (1993). "Life-Threatening Thyrotoxicosis. Thyrotoxic storm. " Endocrinology and Metabolism Clinics of North America 22(2): 263-77.

Burch and Wartofsky Score

Burch, H. B. und L. Wartofsky (1993). "Life-Threatening Thyrotoxicosis. Thyrotoxic storm. " Endocrinology and Metabolism Clinics of North America 22(2): 263-77.

Investigation

• Elevated FT4 and FT3

• Depressed TSH (<0.05 microU/ml)

• Hyperglycemia, hypercalcemia, elevated alkaline

phosphatase, leukocytosis and elevated liver enzymes

• CXR: CHF, possible infectious source

Treatment

• First step: treatment of hyperthyroidism

• Second step: supportive care and prevent

complication

• Third step: correct precipotating factors

Treatment

•Inhibit hormone synthesis: PTU 1200-1500 mg/day

PTU 6 tabs stat then 4 tabs q 4 hr, oral or rectal route

(also inhibit peripheral conversion)

•Inhibit hormone secretion: iodine 200-500 mg/day

SSKI 5 drops q 6 hr or Lugol's 10 drops q 6 hr taper off

in 14 days (start after PTU at least 1-2 hr)

Treatment

• Inhibit peripheral conversion: Dexamethasone 8

mg/day--> 2 mg iv q 6 hr for 3-4 days

• Decrease hormone action: Propranolol 160 mg/day

Beta-blocker Precaution -May result in hypotension in patients who have heart failure and are being treated for thyrotoxicosis -Careful consideration is required -If the cause of heart failure were likely to be underlying tachycardia, beta-blocker would be particularly useful

Treatment • Supportive care:

Nutrition and hydration

Antipyretic drug (not ASA)

Correct heart failure or arrhythmia

• Correct precipitating causes

Outcome • Clinical response in 24-48 hr

• Poor prognosis: coma, jaundice, hypotension

Definitive treatment

• Radioactive iodine ablation:

May not be able to do for several weeks and

months following treatment with iodine

• Surgery

Progression Note

Day Body temp

PR FT3 FT4 Rx.

1 37.4 C 146 13.4 5.5 -PTU 6 tabs stat then 4 tabs q 4 hr -Lugol 10 drops q 6 hr -Dexamethasone 2 mg iv q 6 hr

2 37.5 C 90 4.4 4.7 -PTU 4 tabs q 4 hr -Lugol 10 drops q 6 hr -Dexamethasone 2 mg iv q 6 hr

3 36.8 C 90 3.3 4.8 -PTU 4 tabs q 4 hr -Lugol 5 drops q 6 hr -Dexamethasone 2 mg iv q 6 hr

4 37.0 C 80 3.4 4.1 -PTU 6 tabs qid -Lugol 5 drops q 6 hr -Warfarin(3) 0.5 tab OD hs

5 36.8 C 80 3.6 3.5 -PTU 6 tabs qid -Propranolol(10) 1 tab bid