NECK MASS AND FEVER CHIDINMA NWAKANMA, 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 T 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 STORM Acute, 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 STORM BURCH AND WARTOFSKY’S DIAGNOSTIC PARAMETERS AND SCORING >45 highly suggestive of TS 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! 1.Blockade of peripheral conversion of T4  T3  Dexamethasone 2-4mg IV q6h OR  Hydrocortisone 300 mg IV, then 100mg IV q8h

THYROID STORM TREATMENT 3.Inhibition of thyroid hormone release  PTU mg load then 250 mg Q4 hour (preferred)  Methimazole 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 STORM TREATMENT 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 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