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Diagnosis and Treatment > Signs and Symptoms

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Yuri Tanaka Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Taisuke Uchida Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Hideki Yamaguchi Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Yohei Kudo Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Tadato Yonekawa Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Masamitsu Nakazato Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

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Summary

We report the case of a 48-year-old man with thyroid storm associated with fulminant hepatitis and elevated levels of soluble interleukin-2 receptor (sIL-2R). Fatigue, low-grade fever, shortness of breath, and weight loss developed over several months. The patient was admitted to the hospital because of tachycardia-induced heart failure and liver dysfunction. Graves’ disease with heart failure was diagnosed. He was treated with methimazole, inorganic iodide, and a β-blocker. On the day after admission, he became unconscious with a high fever and was transferred to the intensive care unit. Cardiogenic shock with atrial flutter was treated with intra-aortic balloon pumping and cardioversion. Hyperthyroidism decreased over 10 days, but hepatic failure developed. He was diagnosed with thyroid storm accompanied by fulminant hepatitis. Laboratory investigations revealed elevated levels of sIL-2R (9770 U/mL). The fulminant hepatitis was refractory to plasma exchange and plasma filtration with dialysis, and no donors for liver transplantation were available. He died of hemoperitoneum and gastrointestinal hemorrhage due to fulminant hepatitis 62 days after admission. Elevated circulating levels of sIL-2R might be a marker of poor prognosis in thyroid storm with fulminant hepatitis.

Learning points:

  • The prognosis of thyroid storm when fulminant hepatitis occurs is poor.

  • Liver transplantation is the preferred treatment for fulminant hepatitis induced by thyroid storm refractory to plasma exchange.

  • Elevated levels of soluble interleukin-2 receptor might be a marker of poor prognosis in patients with thyroid storm.

Taxonomy:
Clinical Overview, Gland/Organ, Heart, Liver, Thyroid, Hormone, Thyroxine (T4), Triiodothyronine (T3), TSH, Condition/ Syndrome, Graves' disease, Liver failure, Thyroid storm, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, Asian - Japanese, Country of Treatment, Japan, Diagnosis and Treatment, Signs and Symptoms, Atrial fibrillation, Breathing difficulties, Cardiogenic shock, Cardiomegaly, Coagulopathy, Dyspnoea, Fatigue, Goitre, Heart failure, Hyperhidrosis, Hyperthyroidism, Hypoglycaemia, Hypoxia, Jaundice, Metabolic acidosis, Oedema, Pyrexia, Renal failure, Tachycardia, Weight loss, Investigation, Alanine aminotransferase, Albumin, Alkaline phosphatase, Ammonia, Bilirubin, Brain natriuretic peptide, Calcium (serum), C-reactive protein, Creatinine, CT scan, Echocardiogram, FT3, FT4, Glucose (blood), Lactate dehydrogenase, Potassium, Thyroid antibodies, Transaminase, TSH, X-ray, Intervention, Dialysis, Plasma exchange, Medication, Beta-blockers, Glucocorticoids, Glucose, Hydrocortisone, Methimazole, Potassium iodide, Propylthiouracil, Related Disciplines, Cardiology, Gastroenterology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-19-0078
Volume/Issue:
Volume 2019: Issue 1
Open access
T Min ST4 Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend CF31 1RQ, UK

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S Benjamin Consultant Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend CF31 1RQ, UK

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L Cozma Consultant Diabetes and Endocrinology, Princess of Wales Hospital, Bridgend CF31 1RQ, UK

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Summary

Thyroid storm is a rare but potentially life-threatening complication of hyperthyroidism. Early recognition and prompt treatment are essential. Atrial fibrillation can occur in up to 40% of patients with thyroid storm. Studies have shown that hyperthyroidism increases the risk of thromboembolic events. There is no consensus with regard to the initiation of anticoagulation for atrial fibrillation in severe thyrotoxicosis. Anticoagulation is not routinely initiated if the risk is low on a CHADS2 score; however, this should be considered in patients with thyroid storm or severe thyrotoxicosis with impending storm irrespective of the CHADS2 risk, as it appears to increase the risk of thromboembolic episodes. Herein, we describe a case of thyroid storm complicated by massive pulmonary embolism.

Learning points

  • Diagnosis of thyroid storm is based on clinical findings. Early recognition and prompt treatment could lead to a favourable outcome.

  • Hypercoagulable state is a recognised complication of thyrotoxicosis.

  • Atrial fibrillation is strongly associated with hyperthyroidism and thyroid storm.

  • Anticoagulation should be considered for patients with severe thyrotoxicosis and atrial fibrillation irrespective of the CHADS2 score.

  • Patients with severe thyrotoxicosis and clinical evidence of thrombosis should be immediately anticoagulated until hyperthyroidism is under control.

Taxonomy:
Clinical Overview, Gland/Organ, Thyroid, Topic, Thyroid, Hormone, Thyroxine (T4), Triiodothyronine (T3), TSH, Condition/ Syndrome, Graves' ophthalmopathy, Hyperthyroidism, Thyroid storm, Thyrotoxicosis, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, United Kingdom, Diagnosis and Treatment, Signs and Symptoms, Atrial fibrillation, Goitre, Heart failure, Hypotension, Hypoxia, Pulmonary embolism, Investigation, CTPA scan, Echocardiogram, Electrocardiogram, Liver function, Thyroid antibodies, TSH receptor antibodies, Medication, Carbimazole, Enoxaparin, Glucocorticoids, Related Disciplines, Cardiology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-13-0060
Volume/Issue:
Volume 2014: Issue 1
Open access