Thyroid storm - A case report.

Dear Madam,

Thyroid storm in the perioperative period is an uncommon and life threatening complication of thyrotoxicosis. In our patient who was euthyroid preoperatively, thyrotoxic crisis was precipitated by surgical stress. High degree of suspicion aided by laboratory tests led to successful management of the case.

A 68 year old lady presented with pain in left shoulder, the evaluation of which led to the diagnosis of metastatic follicular carcinoma of thyroid. She was scheduled for total thyroidectomy with lymph node dissection of neck. On preoperative evaluation, she was found to be hypertensive well controlled on medication. She was clinically euthyroid. She underwent surgery without any complications. After 6 h of observation in postoperative ward, she was shifted to her room. On the first postoperative day, she developed fever (102°F) and tachycardia (Heart rate180/min) ECG showed atrial fibrillation. X-ray of chest revealed haziness in the base of both lungs. Patient became breathless and was started on O2 supplementation. Oxygen L saturation was 96% on O2. She was shifted back to postoperative ward. She reverted back to sinus rhythm after a bolus of Inj. Amiodarone 150 mg. Whilst being investigated for perioperative myocardial infarction or sepsis, she experienced a cardiac arrest and high quality CPR with defibrillation for VT was initiated immediately. After defibrillation, return of spontaneous circulation occurred. Her LV function deteriorated and Trop I was positive. Cardiologist suggested coronary angiography after stabilization. She needed high ionotropic support for maintenance of hemodynamics and was also put on ventilatory support. Meanwhile, thyroid function was repeated by the anesthetist and results showed hyperthyroidism (TSH 0.01, T3 54, and T4 26.3). Diagnosis of thyroid storm was arrived based entirely on clinical findings. As we know, there may not be much difference in thyroid hormone levels between uncomplicated thyrotoxicosis and those having thyroid storm.[1] Attending endocrinologist initiated anti- thyroid drugs subsequent to which she improved gradually and could be weaned off inotropic and ventilatory support. She was eventually discharged and continued antithyorid medications with radiotherapy for metastatic active nodule of scapula for which she received radioactive iodine therapy later.

Information on postoperative thyroid storm from a metastatic nodule is scarce. In the case presented, patient was euthyroid preoperatively. Predominant cardiac symptoms in the postoperative period resulted in delay in diagnosis. High degree of suspicion will help in early diagnosis and management. The clinical diagnosis is based on the identification of signs and symptoms. Fever in thyroid crisis is out of proportion to an apparent infection. Similarly, tachycardia is out of proportion to the raise in temperature.

There are scoring systems for diagnosis. On Burch Wartdsky point scale, a score more than 45 is said to be diagnostic [Table 1].[2]

Table 1

Burch Wartdsky points scale for diagnosis of thyroid storm

A score of 45 or more is highly suggestive of thyroid storm
Diagnostic Parameter		Scoring Points
Temperature	37.2-37.7	5
	37.8-38.2	10
	38.3-38.8	15
	38.9-39.4	20
	39.4-39.9	25
	>40	30
CNS effects	Mild (agitation)	10
	Moderate (delirium/Psychosis)	20
	Severe (Seizure/coma)	30
Gastrointestinal -	Moderate (diarrhea)	10
hepatic dysfunction	Severe (Jaundice)	20
Tachycardia	99-109	5
	110-119	10
	120-129	15
	130-139	20
	>140	25
Congestive heart failure	mild	5
	Moderate	10
	Severe	15
Atrial fibrillation	Absent	0
	Present	10
Precipitant history	negative	0
	positive	10
	Total for Points	55

The aims of treatment are:[3]

Supportive care

Inhibition of hormone synthesis

Inhibition of hormone release

Preventing peripheral conversion of thyroxine to triiodothyronine

Beta-adrenergic blockade

Identifying precipitating factors.[4]

Table 2 shows the summary of treatment plan

Table 2

Summary of treatment plan

Steps	Treatment
Step 1	Block Peripheral effect of thyroid hormone. IV beta-blocker
Step 2	Stop the production of thyroid hormone. PTU or Methimazole Dexamethasone or hydrocortisone
Step 3	Inhibit hormone release Iodine 1-2 h after antithyroid medication.

Dialysis and plasmapheresis are last resort for patients not responding to medical treatment.[5]

Altered mentation needs to be treated aggressively for improved outcome.

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Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.