NECK MASS A

ND FEVER

CHIDIN

MA NW

AKANMA, MD

37 yo female, 8 months postpartum, with no significant PMH presenting with swollen right sided neck mass x2 days. She reports having generalized body aches, persistent cough, runny nose, neck stiffness and Tmax of 102. She now also reports dysphagia and odynophagia. She was seen by her PMD 2 days ago and stated on Keflex.

THE CASE…

PHYSICAL EXAM…

Vital Signs:BP 123/66, pulse 113, temperature 101 degrees F, resp. rate 16,

HEENT: R sided neck tenderness and fullness.  No stridor. No difficulty managing secretions.

CV: tachycardia, regular rhythm, no MRG

Lungs: clear lung sounds No wheezing

GI: soft, nondistended, normal bowel sounds

Skin: no rash, clammy

WORK UP…

CBC- WBC 11, HGB 11 HCT 32.3 Plt 200

Chemistry- Na 140 K 3.9 Cl 104 CO2 28 Cr. 1.0 BUN 19 Glu 88

TSH <0.008

T3 9.6

T4 3.48

Cultures pending

CT neck: negative for abscess or lymphadenitis, revealed enlarged right thyroid lobe with areas of decreased attenuation

CXR- hazy opacity in right lower lobe

EKG- sinus tachycardia

DIFFERENTIAL DIAGNOSES

pheochromocytoma

infection

sepsis

neuroleptic malignant syndrome

Hyperthermia

thyrotoxicosis/thyroiditis

thyroid storm

THYROID STORMAcute, severe, life

threatening state of thyrotoxicosis caused by adrenergic hyperactivity or altered peripheral response to thyroid hormone due to one or more precipitants

Clinical diagnosis for patients with existing hyperthyroidism

THYROID STORM PRECIPITANTS:

INFECTION

TRAUMA

SURGERY

STRESS

DKA/HYPOGLYCEMIA

WITHDRAWAL OF ANTITHYROID MEDICATION

IODINE ADMINISTRATION

MYOCARDIAL INFARCTION

PULMONARY EMBOLISM

ECLAMPSIA

VIGOROUS MANIPULATION OF THYROID GLAND

UNKNOWN (20-25%)

THYROID STORMBURCH AND WARTOFSKY’S DIAGNOSTIC PARAMETERS AND

SCORING

>45 highly suggestive of TS25-44 suggestive of impending TS<25 unlikely TS

THYROID STORM

LABORATORY EVALUATION

• elevated Free T4 and FreeT3 levels

• Low TSH

• Chem 8 (low Cr, high Ca)

• CBC (low platelets)

• LFTs (elevated transaminases)

• blood cultures

THYROID STORM

IMAGING

• CXR (or CT chest w/o contrast)

• Thyroid sonogram

• CT neck

• Nuclear medicine imaging with iodine-131

THYROID STORM

TREATMENT

1. Supportive care IV fluid ±dextrose Antipyretics No aggressive cooling!

2. Blockade of peripheral conversion of T4T3 Dexamethasone 2-4mg IV q6h OR Hydrocortisone 300 mg IV, then 100mg IV q8h

THYROID STORM

TREATMENT

3. Inhibition of thyroid hormone release PTU 500-1000 mg load then 250 mg Q4 hour (preferred) Methimazole 60-80 mg QD, divided into doses q4-6 hrs

4. Blockade of hormone production (must be done 1 hour after thionamides)

Potassium Iodide 5 drops PO q6 OR Lugol’s Solution 8 drops PO q 6 OR Sodium Iodide 0.5 mg IV Q 12 hours Lithium Carbonate 300 mg q 6-8 (when iodine is contradicted) 

THYROID STORMTREATMENT

5. Blockade of peripheral β adrenergic receptors• Propanolol 1-2 mg IV q 15 minutes (for HR ≤ 100 bpm)• Then continue maintenance drip (Max 3- 5 mg/hr) OR

• Esmolol 500 mcg/kg !V bolus• Then 50-200 mcg/kg/min maintenance

6. Treatment of underlying precipitant Abx, thrombolytics, insulin, etc

DISPOSITION

• ICU- All thyroid storm patients

•General medical floor- Thyrotoxicosis patients with serious complaint or comorbities

•Discharge with Endocrine/PMD follow- Hyperthyroid patients with minimal sx

TEACHING POINTS

1.Clinical diagnosis: fever, tachycardia, AMS, GI sx

2. Treat thyroid storm while addressing underlying precipitant

3.Aggressive supportive treatment and appropriate level of care

REFERENCES

• Emcrit.org/podcasts/thyroid-storm• EMRAP JUNE 2010 Jonathan LoPresti, MD• “Thyroid Disorders: Hyperthyroidism and Thyroid

Storm; Tintinalli’s Emergency Medicine• Uptodate.com/thyroidstorm