Endocrine Abstracts

A 42-year-old lady, with a diagnosis of Graves’ disease presented with a day’s history of fever, cough, coryzal symptoms and diarrhoea. Being diagnosed with Graves’ disease in 2015, she had been poorly compliant with ATDs. Prior to this presentation, her last FT4 was 31.4 pmo/l with a suppressed TSH. She was intermittently taking propylthiouracil (was intolerant of carbimazole). She had refused RAI and preferred surgery, but hadn’t been keeping up with her ENT appointments. On assessment, she was a bit agitated, pyrexial, tachycardic with crackles being auscultated over the left base. Chest X-ray confirmed a left basal consolidation, her FT4 was 62.1 pmo/l, FT3 was 7.7 pmo/l with a suppressed TSH, and the Burch-Wartofsky score was 55, thus suggestive of thyroid storm. Basic investigations for the aetiology of the pneumonia were sent off. She was started on antibiotics along with intravenous fluids, high doses of propylthiouracil, hydrocortisone, propranolol and potassium iodide. After 48 hours her FT4 had reduced to 49.3 pmo/l, which then normalised by Day 6 of presentation. Simultaneously, her clinical parameters started improving. The result of the viral throat swab was positive for RSV A and B. Since this usually requires symptomatic treatment in immunocompetent individuals, the antibiotics were stopped. The steroids, potassium iodide and beta blockers were omitted once she was clinically and biochemically euthyroid and the propylthiouracil was reduced to her usual maintenance doses. Periodic monitoring of her FT4 showed that she continued to be euthyroid biochemically. Thyroid storm is a rare but potentially fatal condition. Although it can develop in patients with longstanding untreated/irregularly treated hyperthyroidism, it is often precipitated by an acute event such as thyroid or nonthyroidal surgery, infection or an acute iodine load. We believe the RSV infection, coupled with the poorly treated Graves’ led to thyroid storm.