Endocrine Abstracts

A 28-year-old female presented to ED with one week history of flu-like symptoms, palpitations, increasing breathlessness, and productive cough with copious sputum, of two days duration. There was h/o some weight loss over the last year, with episodic palpitations over the last 8-10 years that increased in frequency over the last one year. She had a family history of hyperthyroidism paternally and maternally. On examination, there was mild lid-lag and proptosis. She was tachypnoeic, tachycardic and had a low SO2 of 70% on room air. There were widespread bilateral crackles on lung auscultation. Routine blood tests showed an infective picture with an elevated CRP and White Cell Count. She tested positive for influenza A and Haemophilus influenzae. CT thorax confirmed pneumonitis. She was admitted to ITU and was managed with non-invasive ventilation, nebulisers, IV antibiotics, IV hydrocortisone and fluids. In ITU, her TFTs were deranged, with TSH - <0.004miu/L(0.35-4.94miu/l), free T3 - 21.5 pmol/L(2.9-4.9 pmol/l), and free thyroxine - 47.7 pmol/L(9-19 pmol/l). Anti-TSH receptor and TPO antibodies were positive. She was given propylthiouracil (PTU) and IV hydrocortisone. Whilst this improved the TFTs, she developed neutropenia - 0.0x10^9/l(1.7-6.2x10^9/l). PTU was stopped and after the neutropenia resolved, carbimazole was commenced. At this point, the patient improved clinically from an infection point of view. However, she subsequently developed neutropenia on carbimazole too - 0.6x10^9/l. She was therefore posted for thyroidectomy and received seven days of Lugol’s iodine prior to this. This was an interesting case as there was debate about whether this lady had long-term undiagnosed thyrotoxicosis from Grave’s disease contributing to severe infection, or a thyroid storm. Thyroid storm is a clinical diagnosis, and use of the Burch-Wartofsky Point Scale can help. For our patient, there were various positive signs to suggest thyroid storm, such as a tachyarrhythmia, breathlessness, and productive cough. However, on review, it was determined that these clinical signs were likely due to her severe pneumonia alone. In addition to this and her past history of thyrotoxicosis symptoms, it was concluded that our patient presented with pneumonitis, on a background long standing thyrotoxicosis from untreated Graves’ disease that was diagnosed in this admission, which may have exacerbated her infection and symptoms.