18 1,2 2 2,3 2,3 2,3 (Thyroid storm) (thyrotoxic crisis) (1-4) ( ) (1-4) 22 167/75 mmhg39.7ºc108 / 20 / Glasgow coma scale E3V5M6 thrill bruit 95 10 23 95 11 8 1 2 3 112 201 (02)28757515 (02)28745674 E-mail: hdlin@vghtpe.gov.tw
19 white blood cell count 5,000/mm 3 (N/L: 66/22) hemoglobin 10.7 g/dl platelets 168,000/ mm 3 glucose 120 mg/dl blood urea nitrogen 16 mg/dl creatinine 0.6 mg/dl sodium 136.0 mmol/l potassium 3.4 mmol/l amylase 61 U/L alanine aminotransferace (ALT) 51 IU/L C-reactive protein 0.66 mg/dl 1-3/HPF 2+X X hydrocortisone 100 mg propylthiouracil (PTU) 200 mg propranolol 20 m g PTU 200 mg hydrocortisone 100 mg propranolol 20 mg Lugol solution 10 ciprofloxacin 12 Glasgow coma s c a l e E4V5M6 PTU hydrocortisone propranolol Lugol solution hydrocortisone Lugol solution free thyroxine (free T4) > 6.0 ng/dl ( 0.8-1.9 ng/dl) thyroid stimulating hormone (TSH) 0.004 μiu/ml ( 0.4-4.0 μiu/ml) free T4 3.66 ng/dl, TSH 0.006 μiu/ml Salmonella Shigella Vibrio Compylobacter jejunum Yersinia entrocolitica E. coli O157 (1) (1-4) Apathetic thyrotoxicosis (1,2) (5-10) (11) 108 / (1,2) Burch Wartofsky (1) 99ºF (5-30 ) (0-30 )(0-20 ) 90 / (5-25 ) (0-15 ) (0-10 ) (0-10 ) 25 25 44 (impending thyroid storm)45 50 ( 25 10 510 )
20 PTU propranolol Lugol solution hydrocortisone 12 100% 20% (1) T4triiodothyronine ( T 3 ) ( 1-4 ) thionamide (iodide) iopanoic acid (1-4) P T U t h i o n a m i d e T4T3 B u r c h Wartofky 600-1000 mg 200-250 m g (1) thionamidemethimazole T4T3 (1-4) methimazole (12) PTU 200 mg 200 mg (3) Propranolol 20 80 mg (1-3,13) atenolol metoprolol nadolol (4) esmolol (14) propranolol58 / Lugol s solution T3 T4 10 SSKI 5 iodide thionamide (1-4) T4T3 hydrocortisone 100 mg (1-4) (Lithium) iopanoic acidt4t3 0.5 1 g thionamide (plasma change) (hemoperfusion) (1-4) acetaminophen aspirin aspirin free T4 T3 (1-4) 1. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77. 2. Tietgens ST, Leinung MC. Thyroid storm. Med Clin North Am 1995;79:169 84. 3. Lee CH, Lin HD. Thyroid emergencies: thyroid storm and myxedema coma. In: Clark OH, Duh QY, Kebebew E, eds. Textbook of Endocrine Surgery, 2nd ed. Philadelphia: Elsevier Saunders, 2005:216-22. 4. Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006;35:663-86. 5. Bennett WR, Huston DP. Rhabdomyolysis in thyroid storm. Am J Med 1984;77:733 5. 6. Inoue T, Tanigawa K, Furuya H, et al. A case of thyroid crisis complicated with acute hepatic failure. Nippon Naila Gallai Zasshi 1988; 77:564 7. 7. Ureta-Raroque SS, Abramo TJ. Adolescent female patient with shock unresponsive to usual
21 resuscitative therapy. Pediatr Emerg Care 1997; 13:274 6. 8. Lee TG, Ha CK, Lim BH. Thyroid storm presenting as status epilepticus and stroke. Postgrad Med J 1997;73:61. 9. Bhattacharyya A, Wiles PG. Thyrotoxic crisis presenting as acute abdomen. J R Soc Med 1997;90:681 2. 10. Jiang YZ, Hutchinson K A, Bartelloni P, Manthous C A. Thyroid storm presenting as multiple organ dysfunction syndrome. Chest 2000;118:877-9. 11. Charles RA, Goh SY. Not just gastroenteritis: thyroid storm unmasked. Emerg Med Australas 2004;16:247-9. 12. Thomas DJ, Hardy J, Sarwar R, et al. Thyroid storm treated with intravenous methimazole in patients with gastrointestinal dysfunction. Br J Hosp Med (Lond) 2006;67:492-3. 13. Ngo AS, Lung Tan DC. Thyrotoxic heart disease. Resuscitation 2006;70:287-90. 14. Duggal J, Singh S, Kuchinic P, Butler P, Arora R. Utility of esmolol in thyroid crisis. Can J Clin Pharmacol 2006;13:e292-5.
22 Thyroid Storm: A Case Report Por-Wen Yang 1,2, Huei-Fang Wang 2, Sin-Yun Hsiao 2,3, Shih-Tzer Tsai 2,3, Hong-Da Lin 2,3 Clinical presentation of thyroid storm is usually nonspecific. Diagnosis and treatment may be delayed if the emergency physician is not familiar with the disease. We report on a patient with a prior history of hyperthyroidism, suffering from abdominal pain, nausea and diarrhea for two days, followed by fever for one day. She received an initial diagnosis of infective gastroenteritis. Disturbed consciousness later developed and thyroid storm was eventually confirmed. The patient recovered after appropriate treatment. Differential diagnosis of hyperthyroidism patients presenting with diarrhea, fever, and disturbed consciousness should include thyroid storm, even with a history of travel to developing countries. Key Words: fever, gastroenteritis, thyroid storm Received: October 23, 2006 Accepted for publication: November 8, 2006 From the 1 Department of Internal Medicine, Tao-Yuan General Hospital, Department of Health, the Executive Yuan, Republic of China 2 Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital 3 National Yang-Ming University School of Medicine Address for reprints: Dr. Hong-Da Lin, Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital 201 Section 2, Shih-Pai Road, Taipei, Taiwan (R.O.C.) Tel: (02)28757515 Fax: (02)28745674 E-mail: hdlin@vghtpe.gov.tw