SESSION TITLE: Critical Care Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: We describe a case of atypical TS; normotensive, normothermic, without any signs of CNS or GI symptoms, leading to multi-organ-dysfunction-syndrome (MODS), including disseminated intravascular coagulation (DIC).
CASE PRESENTATION: A 64-year-old female with questionable thyroid disorder on kelp, presented with progressively increasing dyspnea. On exam, she was a cachectic woman weighing 46.6 kg with moderate respiratory distress, BP 153/102 mmHg. She had an enlarged, irregular thyroid gland, irregular tachycardia with a systolic murmur, marked jugular venous distention and diminished breath sounds bilaterally at lung bases. Labs included elevated BNPT (1557) and TSH <0.01 mcIU/ml. Chest x-ray showed cardiomegaly with bilateral pleural effusions. She was placed on Venturi mask, heparin by weight, propranolol and hydrocortisone for the new onset Afib and TS. The night of admission, she developed PEA and was successfully resuscitated, placed on mechanical ventilation and noted to be hypotensive and bradycardic requiring norepinephrine and vasopressin infusion. After 24 hours, she had MODS with respiratory failure, anion gap metabolic acidosis, hepatic failure, renal failure, lactic acidosis and melena with drop in Hb, platelets and fibrinogen indicating DIC. Labs revealed elevated free and total T3, T4. Transthoracic echocardiogram showed a left ventricular EF of 25%. Endocrinologist initiated her on propylthiouracil and potassium iodide for TS. Despite aggressive resuscitation, the patient deteriorated and died 36 hours after presentation.
DISCUSSION: TS is a rare disorder with sudden onset, rapid progression and high mortality. We witnessed a case of TS with a devastating course leading to MODS, DIC and eventually death, despite early recognition and aggressive resuscitation. Very few cases of TS with DIC have been reported. The diagnostic criteria for TS used worldwide were established by Burch, et al; a score of > 45 suggests TS. Our patient scored 60. More recently, Japan Thyroid Association and Japan Endocrine Society came up with additional criteria. As per these criteria, our patient had elevated FT3, FT4 and had two of the five symptoms. TS is precipitated by an acute critical condition. In our patient, the cause of TS was multifactorial, including acute onset congestive failure, consumption of kelp, medical noncompliance and/ or clinical palpation of her thyroid gland.
CONCLUSIONS: TS is a medical emergency. Early diagnosis based on the criteria and intervention is critical for survival.
Reference #1: Akamizu T et al. Diagnostic criteria and clinico-epidemiological features of thyroid storm based on a nationwide survey. Thyroid 22 (7): 661-679, 2012.
DISCLOSURE: The following authors have nothing to disclose: Amareshwar Podugu, Khulood Rizvi, Chandra Dasari, Asha Chakka, Nihad Boutros
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