Thyroid Storm in the Setting of Subacute Thyroiditis PGY-2 Case - PowerPoint PPT Presentation

Thyroid Storm in the Setting of Subacute Thyroiditis PGY-2 Case Conference Jordan Groubert, PGY-2 11/5/2019 1

Outline 1. Review Case 2. Discuss Disease Pathogenesis 3. Discuss Differential Diagnosis 4. Discuss Diagnostic Criteria 5. Discuss Treatment 6. Patient Update 2

History of Present Illness 3

History of Present Illness • 19 y/o female presented with a 2-3 day history of generalized pain, confusion, nausea, emesis and right upper extremity swelling. On presentation she was encephalopathic, intermittently crying out in pain and only able to answer some yes/no questions. The majority of the history was provided by the patient’s father. 4

Medical History 5

Past Medical History • IV drug abuse o Last admitted drug use was 6 months prior, but family was suspicious for active use o “Pink powder” found at home by her father • MRSA abscesses • No prior history of thyroid disorders 6

Past Surgical History • No prior surgical history 7

Family History • No pertinent family history o No known family history of thyroid disorders 8

Social history • Current 1 ppd smoker, 5 pack-year history • Denied alcohol use • IV heroin/fentanyl use • Lives at home with her father 9

Review of Systems 10

Review of Systems • ROS positive for o Generalized pain o Nausea o Emesis o Right upper extremity swelling • Reliable ROS unable to be obtained upon admission due to encephalopathy 11

Physical Exam 12

Physical exam • Vitals: Temp 99.3 F, HR 143, RR 40, SpO2 97% RA, BP 93/57 (68) • General: Ill-appearing, moderate distress, diaphoretic • HEENT: NCAT, PERRL, EOMI, Poor dentition. No exophthalmos/ophthalmopathy. • Neck: Diffusely enlarged thyroid with tenderness to palpation, no bruit. • CV: Tachycardia, regular rhythm, no murmurs • Thorax: Tachypnea, bilateral crackles, labored respirations • Abdomen: Bowel sounds present, generalized tenderness, non-distended, no organomegaly, no rashes • Extremities: Track marks on bilateral upper/lower extremities, no peripheral edema, no pretibial myxedema • Neuro: Moves all extremities, sensation grossly intact, no focal deficits • Integument: Track marks • Psych: anxious and agitated, intermittently crying out in pain, AOx1 13

Labs and Imaging 14

Labs Troponin: 1.530 134 32 96 TSH: 0.026 162 22 0.77 3.6 Free T3: 16.9 Free T4: > 6.99 Lactic Acid: 3.7 12.5 23.3 83 36.4 UDS: negative 15

Imaging • CT Neck Soft Tissue • Generalized edema throughout the soft tissues of the neck with prominent swelling and edema involving the thyroid gland. Findings concerning for thyroiditis. • Thyroid US • Large and heterogenous gland with no normal thyroid tissue appreciated. No focal nodules noted. No evidence of increased vascularity on color doppler. 16

Thyroid US 17 Summa Health Sample Preso

Hospital Course • Admitted to the ICU for management of thyrotoxicosis and started on empiric antibiotics for sepsis o Blood cultures positive for MRSA; TTE showed tricuspid valve endocarditis • Endocrinology was consulted and started: o Methimazole o Propranolol o Hydrocortisone o Cholestyramine • Patient endorsed anterior neck pain, palpitations, diaphoresis and heat intolerance for 2-3 days before presentation • Thyroid receptor antibody (TRAb ) was negative, ruling out Grave’s disease o Methimazole was stopped • TPO antibody was negative, ruling out Hashimoto’s thyroiditis • Repeat thyroid ultrasound continued to show evidence of thyroiditis o Thyroiditis attributed to septicemia/endocarditis/systemic inflammation • Patient’s condition gradually improved and steroids were tapered 18 11.05.19

Thyroid Storm 19

Thyroid Storm • Thyroid storm is a rare, life-threatening manifestation of thyrotoxicosis o 20-30% mortality rate o Affecting only 1% of thyrotoxic patients • Most common in patient’s with an underlying hyperthyroid state (Grave’s Disease, toxic multinodular goiter or solitary toxic adenoma) who have an inciting event o Thyroid or non-thyroidal surgery o Infection o Trauma o Acute iodine load o Childbirth o Irregular use or discontinuation of anti-thyroid drugs (ex. methimazole, propylthiouracil) • Very few documented cases of thyroid storm in the setting of subacute thyroiditis 20

Presentation • Patients present with severe signs/symptoms of thyrotoxicosis o Hyperpyrexia o Tachycardia o Heart failure o Hypotension o Diarrhea o Confusion/delirium o Anxiety/agitation • Physical exam o Goiter may or may not be present • Labs o Suppressed TSH, elevated Free T3/T4 o Degree of Free T3/T4 elevation doesn’t necessarily correlate with severity of symptoms 21 06.06.2016 Summa Health Sample Preso

Pathogenesis • Excess release of circulating thyroid hormones • Mechanism of hormone release differs depending on underlying hyperthyroid condition o Ex. Graves Disease, subacute thyroiditis, toxic multinodular goiter etc. 22

Differential Diagnosis • Drug intoxication • Hypertensive emergency/hypertensive encephalopathy • Infection/sepsis • Neuroleptic malignant syndrome • Pheochromocytoma • Psychosis 23 06.06.2016 Summa Health Sample Preso

Diagnosis • Diagnosis is based on signs/symptoms of thyroid storm in individuals with suppressed TSH and elevated Free T3/T4 • The Burch-Wartofsky score is used to aid in the diagnosis • Scoring system: • < 25: thyroid storm unlikely • 25-44: impending thyroid storm • > 45: highly suggestive of thyroid storm • In this case, the Burch-Wartofsky score was 75 24

Workup • Labs o TSH, Free T3, Free T4 o TSI or TRAb • Imaging o Thyroid ultrasound o CT neck soft tissue o Radioiodine uptake and scan 25

Treatment • Patients require management in the ICU • Management includes: o Beta-blockers • Management of signs/symptoms related to increased adrenergic tone o Thionamides (methimazole or propylthiouracil) • Decrease synthesis and peripheral conversion of thyroid hormones o Glucocorticoids • Reduce peripheral conversion of T4 to T3 conversion • Promote vasomotor stability • Reduce inflammation (if present) o Bile acid sequestrants • Decrease enterohepatic recycling of thyroid hormones o Iodine (iodinated contrast or iodine tablets) • To be given after administration of anti-thyroid medications to prevent worsening of thyrotoxicosis • Decrease release of T3 and T4 from the thyroid 26

Subacute Thyroiditis • Inflammation of the thyroid usually in the setting of viral illness or a post-viral inflammatory process • Pathogenesis: destruction of thyroid follicles and proteolysis of thyroglobulin causing release of T3 and T4 • Presentation o Anterior neck pain o Diffuse goiter with tenderness to palpation o Signs/symptoms of hyperthyroidism/thyrotoxicosis with associated laboratory abnormalities • Thyrotoxicosis is usually mild • Severity of signs/symptoms don’t necessarily correlate with degree of lab abnormalities • Imaging o Ultrasound: hypoechoic appearance, may be normal or enlarged o Radioiodine uptake and scan: low uptake in the hyperthyroid phase • Treatment: o Pain control and beta blockers o Thionamides are not indicated • Clinical course o Hyperthyroid  Euthyroid  Hypothyroid  Recovery 27 Summa Health Sample Preso

Patient update • Discharged to acute rehab following complicated ICU course • No outpatient follow-up to date 28

Acknowledgements • Ahmad Al-Shoha, MD • Mansur Assaad, MD • Bisher Zuhdi, MD 29

References • Salih AM, Kakamad FH, Rawezh QS, et al. Subacute thyroiditis causing thyrotoxic crisis; a case report with literature review. Int J Surg Case Rep. 2017;33:112-114. • Swinburne JL, Kreisman SH. A rare case of subacute thyroiditis causing thyroid storm. Thyroid. 2007;17(1):73-6. • Fatourechi V, Aniszewski JP, Fatourechi GZ, Atkinson EJ, Jacobsen SJ. Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study. J Clin Endocrinol Metab. 2003;88(5):2100-5. • MKSAP • Uptodate 30

Questions? 31

Thank you 32

Severe Cardio-Renal Syndrome Responding to Very High Dose Lasix Drip Dan Redle MD, Bisher Zhudi MD, Chris Tanayan MD, Charina Gayomali MD

Overview  Review Case  Pathophysiology  Differentials  Treatment  Patient Update  References

HPI  61 yo M presented to ACH ED 4/3/19 with acute on chronic SOB with cough, bilateral leg pain, chills, arthralgias, nausea. In ED, vital signs initially remarkable for increased work of breathing with RR of 22 and patient required BiPAP .

Medical and Social History  PMH: CAD, HFrEF (25%), Afib,CKD, Apical Thrombus, COPD, T2DM, OSA, DVT , HTN, HPL, Gout, Back Pain  PSH: CABG, Atrial Ablation, Embolectomy RLE  FMH: Father: Lung Cancer  Social: Single, known hoarder, denied tobacco/EtOH/illicit drug use