Endocrine Abstracts

Introduction: Thyroid storm or thyrotoxic crisis is a severe manifestation of thyrotoxicosis. Mortality rate is 20-30%. The most common trigger is hyperthyroidism due to Graves-Basedow Disease. There are two validated scales for diagnosis: the Burch Wartofsky scale (BWPS) and the Japanese Thyroid Association scale (JTA). These scales are based on cardiovascular, neurological, digestive, and thermoregulatory clinical manifestations. If clinical suspicion is high, treatment should not be delayed in order to identify and treat precipitating factors, achieve euthyroid state, and address multiorgan damage.

Presentation of the case: A 37-year-old woman with Graves-Basedow Disease without treatment presented to the Emergency Department with symptoms of dyspnea, edema, fever, cough, vomiting, diarrhea, nervousness, and palpitations. On arrival, she had a fever of 38.5ºC, diffuse grade III goiter with a murmur and thrill, and fine distal tremor. Laboratory tests showed hepatic profile alteration and elevated levels of Nt-proBNP and acute phase reactants. Electrocardiogram revealed sinus tachycardia at 137 bpm; bilateral pleural effusion and left bronchopneumonia were observed on chest X-ray. Due to an elevated D-dimer, thrombosis was ruled out with Doppler ultrasound and CT angiography. Echocardiogram showed no structural heart disease. Microbiological isolates were negative. Thyroid profile tests showed suppressed TSH, free T4 at 3.2 ng/dl, and free T3 at 4.78 pg/ml. Suspecting an incipient thyrotoxic crisis, high-dose antithyroid drugs, beta-blockers, steroids, diuretics, and antibiotics were initiated. The ICU was consulted and decided not to admit the patient due to stability and prompt initiation of treatment. The patient was diagnosed with left basal pneumonia that triggered a thyrotoxic crisis with multiorgan dysfunction (BWPS 75). At the first follow-up visit two weeks after discharge, she showed favorable progress, leading to consensus on I131 treatment.

Conclusions: Thyrotoxic crisis is a potentially life-threatening condition that can cause multiorgan dysfunction. Therefore, clinical suspicion and early initiation of treatment are important.