A Different Kind of Storm: Prompt Identification and Management of Thyrotoxicosis in Children

Cristina E. Alcorta, MD (’22)

Case: A 15 year-old girl with no significant past medical history presented for initial evaluation of hyperthyroidism to the Pediatric Endocrinology Clinic. She had been experiencing new symptoms, including palpitations, shortness of breath, tremors and weight loss. On laboratory work-up, she was found to have a suppressed TSH and an elevated Free T4. T3 and TSI were pending. She was tachycardic and hypertensive. On further examination, she had a diffuse goiter without nodules on palpation. The Endocrinologist recommended starting atenolol 25mg daily and methimazole 20mg PO BID. Initial plan consisted of BP/HR check at her primary care physician’s office later that week to decide whether she needs a higher atenolol dose and repeat TFTs in two weeks to assess trend. She received a preliminary diagnosis of Graves Disease while awaiting the TSI. At the two-week mark, the patient reports experiencing anaphylaxis to methimazole requiring Epipen administration. She was continued on atenolol 25mg daily with plan for urgent thyroidectomy. Her parents agreed to proceed with surgery; however patient was briefly lost to follow-up, suspected to be secondary to her parents not understanding the gravity of her condition. She presented two weeks later to the emergency department with a fever of 100.9F and vomiting. Additional vitals included HR 90-120s, RR 22, SpO2 99%. She reported a sensation of chest pain and dizziness.

Thyroid Storm is a rare, life-threatening condition that is characterized by an exaggeration of hyperthyroidism symptoms. It is an endocrine emergency that requires prompt identification and management. Thyroid storm is characterized by multisystem organ failure and clinical features that include nausea, vomiting, diarrhea, cardiovascular dysfunction (hypotension, arrhythmias, congestive heart failure), and hepatic dysfunction. Patients will present with altered mental status or even seizure if not caught at earlier stages. Several factors can precipitate thyroid storm, including abrupt cessation of anti-thyroid drugs, inadequately treated hyperthyroidism (likely the case for our patient), and acute illness (such as DKA).

A useful tool in determining the diagnosis of thyroid storm is the Burch and Wartofsky point scale, noted in the table below. According to the point scale, our patient scores a 30, suggestive of “Impending Storm.” She scored 10 points each for Tmax 100.9F, gastrointestinal symptoms of nausea/vomiting and HR of 110-119.

Burch and Wartofsky
Table: Bahn Chair et al. 2011, Reference 2

Treatment includes: (1) beta-blockade with propranolol or esmolol; (2) fast-acting anti-thyroid medications that prevent T4-to-T3 conversion, such as PTU; (3) inorganic iodine solutions for acute inhibition of thyroid hormone secretion and synthesis, such as Lugol Solution (potassium iodide); and (4) corticosteroid therapy to potentiate inhibition of T4-to-T3 conversion.

Our patient highlights several important considerations, including the need to adequately provide patient education regarding a potential life-threatening diagnosis and consideration of treatment alternatives for allergies. Supportive measurements may also be necessary, including cooling with ice/cooling blankets, use of antipyretics, volume resuscitation and respiratory support as needed.

References:

  1. Shylaja Srinivasan, Madhusmita Misra; Hyperthyroidism in Children. Pediatr Rev June 2015; 36 (6): 239–248. https://doi.org/10.1542/pir.36-6-239
  2. Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN; American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011 Jun;21(6):593-646. doi: 10.1089/thy.2010.0417. Epub 2011 Apr 21. Erratum in: Thyroid. 2011 Oct;21(10):1169. Erratum in: Thyroid. 2012 Nov;22(11):1195. PMID: 21510801.
  3. Guido Alarcon, Veronica Figueredo, Joshua Tarkoff; Thyroid Disorders. Pediatr Rev November 2021; 42 (11): 604–618. https://doi.org/10.1542/pir.2020-001420

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