Thyroid Storm with Case

00:01 In this case, a 19 year old man was admitted to the hospital with acute ruptured appendicitis three days ago.

00:08 He has a history of Graves' disease previously treated with methimazole and propranolol.

00:14 On exam, his temperature is 39 degrees celsius, his blood pressure is a 100/50 mm Hg and his heart rate a 125 beats per minute and irregular.

00:25 He is confused, diaphoretic and warm to the touch.

00:29 His thyroid gland is enlarged but not tender.

00:33 He has lid lag and bilateral hand tremor on exam.

00:38 What is the most likely diagnosis? Here we have a young man with a history of Graves' disease after admission to the hospital with appendicitis.

00:47 We also note that he is not taking any medications.

00:51 On exam, he has a fever, a low blood pressure and tachycardia with an irregular heart rhythm suggesting atrial fibrillation and cardiovascular shock.

01:02 He has enlarged, non-tender thyroid gland with lid lag and a hand tremor - all suggestive of hyperthyroidism and recurrence of his Graves' disease.

01:12 The most likely cause of this presentation which is extremely dramatic, manifesting with the presence of shock is thyroid storm.

01:21 Thyroid storm is a rare condition and is a severe manifestation of thyrotoxicosis with a life threatening secondary systemic decompensation.

01:31 Clinically, the patients may have increased temperature, they may have significant tachycardia and heart failure, they may have irregular heart rhythms in the form of atrial fibrillation.

01:41 Nausea, vomiting, diarrhea or jaundice may accompany their condition.

01:45 Neurologic disturbances including increased agitation, emotional liability, confusion, paranoia and psychosis which all may progress to coma.

01:57 This occurs most commonly when Graves' disease is coupled with a precipitating factor like a severe infection, surgery, a myocardial infarction, radioactive iodine treatment or in pregnancy.

02:11 The mortality rate for this condition is 15 to 20% For patients who present in thyroid storm, always find the precipitating cause.

02:21 Treat the patients with thionamide drugs, provide beta blockers to reduce the tachycardia and iodine drops in high dose or high dose glucocorticoids can also be used to mitigate the symptoms.