Endocrine Abstracts

Thyrotoxic crisis is a manifestation of an extreme and rare state of thyrotoxicosis. It is an acute, life-threatening state. The mortality of thyrotoxic crisis is currently reported at 8–25% [1]. The clinical presentation includes fever, tachycardia, hypertension followed by congestive heart failure, neurological and mental disorders. We present a case of 34-year-old woman without any history of thyroid hyperactivity. She was admitted to hospital after premature amniotic fluid leakage in 34th week of her second pregnancy and complained of intensive dyspnoe. After patient full examination it was decided to deliver the baby by Caesarean section because of progression of cardiopulmonary failure (her heart rate was 156 bpm, blood pressure 181/91 mmHg, respiratory rate 44 bpm, O₂ saturation 91%, ejection fraction was 30%). After section her condition remained critically serious and she moved to intensive care. Her respiratory failure required ventilatory support for 11 days, she had fever (T 39.6 °C), uncontrolled tachycardia and hypertension despite treatment. Although she was initially thought to have severe preeclampsia with pulmonary oedema complicated pneumonia, but her thyroid function tests indicated severe thyrotoxicosis: TSH <0.01 (normal 0.4–3.6 mU/l), free T₃ 35.35 (normal 3.34–5.14 pmol/l), free T₄ 82.58 (normal 9–21.07 pmol/l). This clinical picture was consistent with a diagnosis of thyrotoxic crisis. Treatment was started with thiamazole 80 mg/d, intravenous hydrocortizone 200 mg/d, Lugol’s iodine 5% 20–30 drops/d, propranolol 160 mg/d and supportive care. Despite thyroid decreasing function, 7th day after section patient state remains difficult and it was decided to increase thiamazole dose to 120 mg/d, hydrocortizone to 300 mg/d and change propranolol to metoprolol 200 mg/d. Following 2 weeks on intensive care she made a remarkable recovery. She was discharged home on the 32nd postoperative day with a healthy baby. Now she is on endocrinologist control, her last anti-TPO was 2354 (normal 0–12 kU/l), anti-Tg 51 (normal 0–100 kU/l), anti-TTH 15.2 (normal <9 U/l). Thyroid ultrasound – thyroid gland was enlarged, hypoechogenic and heterogeneous structure because of hypoechogenic zones. According to test results it was diagnosed Graves’ disease. It is almost one year after thyroid storm, she still has persistent subclinical hyperthyroidism despite consistent treatment with thiamazole. So, we are considering thyroidectomy. Reporting this case we want physicians to be aware of this rare situation as symptoms of thyrotoxic crisis are similar to those of preeclampsia.