Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Case Report
Year : 2019 | Volume : 6 | Issue : 3 | Page : 54 - 55

Thyroid Storm (Accelerated Hyperthyoidism) : A Challenging Medical Emergency

Neeraj kumar1, Madhu Singh2, R Dayal3, Kundan Mittal4

1Professor, 2Lecturer, 3Professor and Head, Department Of Paediatrics, S.N.Medical College, Agra, Uttar Pradesh, India. 4Senior professor and Incharge PICU and Respiratory Clinic,PGIMS Rohtak, Haryana, India

Correspondence Address:

Dr.Kundan Mittal,Senior Professor Pediatrics
Pt B D Sharma, PGIMS, Rohtak, Haryana, India,
Phone : +919416514111, Email : kundanmittal@gmail.com
Received: 11-Mar-19/Accepted: 17-May-19/Published online:05-Jun-19

Source of Funding:None Conflict of Interest:None

DOI:10.21304/2019.0603.00505


ABSTRACT
Thyroid storm is an uncommon but potentially lethal medical emergency. Thyroid hormone is present in excess leading to a hyper-metabolic state characterized by high grade fever, excessive sweating, palpitations which can rapidly progress into delirium, coma, and death. Precipitating events include trauma, infection, radioactive iodine treatment, or surgery.

Key-words:
T3(Tri-iodothyronine), T4(Tetra-iodothyronine), TSH-Thyroid stimulating Hormone, Thyroid storm.

Introduction
Thyroid gland is a butterfl y shaped gland located in the neck which affects nearly every organ in the human body. It produces two hormones namely T3 and T4, which are under feedback control of hypothalamus and pituitary gland hormones (TRH and TSH). Thyroid hormones should be present in a state of equilibrium as their excess can cause increased metabolic rate, heart rate, ventricle contractility, and gastrointestinal motility as well as muscle and central nervous system excitability. Hyperthyroidism denotes a metabolic state in which thyroid hormone is produced in excess owing to intrinsic thyroid gland hyper-function, whereas thyrotoxicosis refers to excess circulating thyroid hormone originating from any cause (including thyroid hormone overdose).
Thyroid storm or accelerated hyperthyroidism is a rare but devastating presentation of thyrotoxicosis manifesting as an abrupt life-threatening hypermetabolic state usually precipitated by infection, trauma or surgery. It is proposed to be caused either by excessive release of thyroid hormones, causing adrenergic hyperactivity, or altered peripheral response to thyroid hormone following the presence of one or more precipitants.

Case report
A 15 years old boy presented in our emergency department with complaints of high-grade fever on & off, loose watery stools and excessive sweating since the past one month. Nausea was present 15 days back which improved after anti-emetics prescribed by a local practitioner. Mother complained that he preferred to sit under tap water for the last 12 days. He had palpitations for 5 days.
On physical examination his hands were sweaty. Axillary temperature was recorded to be 102 oF. B/L Eyes were protruding. On examination of his neck a uniform bulge was appreciated which moved upwards on deglutition.
His heart rate was 124 beats per minute. Respiratory rate was 32 per minute with bilateral equal air entry. No additional sounds were appreciated on auscultation.
This child was immediately given humidifi ed oxygen by nasal prongs and cold sponging started. 2 wide bore cannula were put and Normal saline bolus @ 20 mL/ kg was given immediately. Inj. Acetaminophen 1 mL was given intramuscularly. Routine blood investigations like Complete blood counts and Random blood sugar were sent. Blood culture and urine culture were sent before fi rst dose of antibiotics. Blood sample for thyroid profi le (TSH, FT3 and FT4) was sent as the clinical picture was suggestive of thyroid storm.Meanwhile, we found that his reports have Low TSH with very high FT3 and FT4.
The child was given fi rst dose of Injection Ceftriaxone. Propylthiouracil (PTU) 100 mg was given every 6 hourly orally. Inj.Ciplar LA 40 mg was given every 12 hourly. Dexamethasone was given at the dose of 2 mg every 12 hourly. The child stabilized after 48 hours. To confi rm our fi ndings, we evaluated the child for thyroid antibodies. The child had positive results for thyroid stimulating antibodies.
Inj. Dexamethasone was continued for 3 days. After the thyroid storm was under control Methimazole, 40 mg given PO as loading dose followed by 25 mg every 4 h was given to make the child euthyroid.The child was closely monitored for a week and discharged thereafter with plans for defi nitive therapy to prevent a future recurrence of life-threatening thyrotoxicosis.

Discussion
Thyroid storm or accelerated hyperthyroidism is a relatively uncommon but a catastrophic medical emergency which needs immediate diagnosis and treatment. It is a medical emergency due to metabolic impact of excessive thyroid hormones present in the blood, which without treatment can progressively lead to unconsciousness, coma, heart failure, arrhythmias or even death. A history of thyroid nodule/ trauma/ surgery/ and or intake of anti-thyroid drugs are important predictors. Medical as well as supportive management should be done promptly to abate acute crisis and curtail the symptoms. Surgery and/or radioactive iodine are the defi nitive cure if medical treatment fails to combat thyroid storm.

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