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Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 35  |  Issue : 4  |  Page : 559-560

Thyroid storm – A case report


1 Department of Anesthesia, GKNM Hospital, Coimbatore, Tamil Nadu, India
2 Department of Surgical Oncology, GKNM Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication13-Dec-2019

Correspondence Address:
Dr. Rajani Sundar
205, Manchester Regend 693, Avinashi Road, Coimbatore - 641 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_80_18

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How to cite this article:
Sundar R, Ramaswamy M. Thyroid storm – A case report. J Anaesthesiol Clin Pharmacol 2019;35:559-60

How to cite this URL:
Sundar R, Ramaswamy M. Thyroid storm – A case report. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2020 Apr 4];35:559-60. Available from: http://www.joacp.org/text.asp?2019/35/4/559/272955



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

Click here to view


The aims of treatment are:[3]

  1. Supportive care
  2. Inhibition of hormone synthesis
  3. Inhibition of hormone release
  4. Preventing peripheral conversion of thyroxine to triiodothyronine
  5. Beta-adrenergic blockade
  6. Identifying precipitating factors.[4]


[Table 2] shows the summary of treatment plan
Table 2: Summary of treatment plan

Click here to view


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

Altered mentation needs to be treated aggressively for improved outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical features and hospital outcomes in thyroid storm: A retrospective cohort study. J ClinEndocrinolMetab 2015;100:451-9.  Back to cited text no. 1
    
2.
Burch HB, Wartofsky L. Life-threatening thyrotoxicosis: Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77.  Back to cited text no. 2
    
3.
Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I,et al. Hyperthyroidism and other causes of thyrotoxicosis: Management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. EndocrPract2011;17.  Back to cited text no. 3
    
4.
Papi G, Corsello SM, Pontecorvi A. Clinical concepts on thyroid emergencies. Front Endocrinol (Lausanne) 2014;5:102.  Back to cited text no. 4
    
5.
Ashkar FS, Katims RB, Smoak WM 3rd, Gilson AJ. Thyroid storm treatment with blood exchange and plasmapheresis. JAMA 1970;2141275-9.  Back to cited text no. 5
    



 
 
    Tables

  [Table 1], [Table 2]



 

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