Morning Report

1. Morning Report Kimberly Smith 7/20/2010

2. MKSAP A 23-year-old woman comes to the office for follow-up. The patient has a 5-year history of hypothyroidism and has been on a stable dose of levothyroxine for the past 3 years. She is now 6 weeks pregnant with her first child. Physical examination findings are noncontributory. Results of laboratory studies 1 month ago showed a serum thyroid-stimulating hormone (TSH) level of 2.9 µU/mL (2.9 mU/L) and a free thyroxine level of 1.4 ng/dL (18.1 pmol/L).

3. Which of the following is the most appropriate management? A. Add iodine therapy B. Measure her free triiodothyronine (T3) level C. Recheck her serum TSH level D. Continue current management

4. The most appropriate next step is to recheck TSH. Because a fetus depends on maternal thyroid hormone for the first 10 to 12 weeks, the thyroid should be carefully monitored. TSH and total thyroxine (T4) levels be monitored throughout pregnancy because free T4 levels are not as accurate in pregnant patients. The total T4 level should be kept stable at approximately 1.5 times the normal range, and the TSH level should be kept in the lower range of normal. Because of estrogen elevation during pregnancy, TBG levels increase. Free T4 levels may decrease as more T4 becomes bound by TBG. Pregnant patients may require an increase in their levothyroxine of approx 35% to 50% as early as the first trimester. Measurement of T3 level is not useful in the evaluation of hypothyroidism because T3 levels typically remain within the reference range until the point of severe hypothyroidism.

5. The Case….. 40 y/o AAF who presented to the ER with chest pain and dyspnea Additional Questions?

6. Pertinent HPI PTA c/o sore throat, difficulty swallowing, and decreased PO intake x 5 days. Initially presented to an OSH ER where she received antibiotics for presumed strep pharyngitis She then re-presented with chest pain and dyspnea and received a course of Avelox for presumed CAP Symptoms progressed, began experiencing ear pain, pleuritic right sided chest pain, shortness of breath, cough productive of brown sputum, chills, tremors in bilateral hands, N/V Upon further questioning she notes ~ 10lb weight loss, mood swings, anxiety, decreased appetite, and difficulty concentrating over the past month

7. History PMH None- however patient has not been to the doctor in many years PSH None Social History Remote history of smoking Black and Mild's and marijuana but she quit >1 year ago, occasional alcohol, denies illicit drugs Family History Noncontributory Medications None Allergies NKDA

8. Differential Diagnosis Pulmonary Pneumonia PE Pleuritis Cardiovascular ACS AS CHF Pericarditis Myocarditis Heme Malignancy GI GED Esophagitis Rheum Sarcoid Vasculitis Endocrine Hyperthyroid Hypercalcemia Pheochromocytoma Infectious Influenza HIV EBV HiB Upper Airway Thermal injury Foreign body Caustic ingestion

9. Physical Exam 38 C, 109, 170/80, 20, 98% RA General: Extremely agitated female, tachypnic, writhing in pain HEENT: NC, TTP over mastoid sinuses but no erethyma/rash/swelling, PERRL, normal conjunctiva, sclera anicteric, no pharyngeal erethyma/exudates/swelling, no proptosis Neck: supple, thyromegaly- 4 finger widths, no cervical lymphadenopathy Respiratory: coarse breath sounds, wheezes R>L lower lobes CV: Tachycardic, normal rhythm, nl S1/S2, no murmurs, no JVD or edema, right sided chest wall tenderness GI: soft, NTND, + BS, no rebound or guarding Neurologic: A x O x 3 Skin: no C/C/E

10. Studies?

11. Initial Labs

12. Additional Studies

13. TSH <0.03 Throat Culture: Negative Strep Pneumo/Legionella: Negative Neck Xray: c/w prevertebral swelling CT Neck and chest: Enlarged adenoids, tonsils, cervical lymph nodes, thyromegaly, negative for PE

14. Initial Assessment and Plan RUL PNA Initiated therapy with Vancomycin and Zosyn Morphine PRN

15. Patient is still very agitated despite attempting to control her pain, remains tachycardic despite IVF and initiation of broad spectrum antibiotics, begins having multiple episodes of emesis

16. Diagnostic Criteria for Thyroid Storm

17. Our Patient Temp 38 Mild agitation c/o N/V Tachycardic to 104 Positive Precipitant History Total Score 45

18. Thyroid Storm AKA Thyrotoxic crisis Incidence 1-2% The adult mortality rate is 20-50% Mortality rises to 75% with delays in treatment More common in females Incidence is highest in the third and fourth decades of life

19. Precipitating Events Infection Surgery RAI therapy Drugs ASA, NSAID’s, chemotherapy, anticholinergics Excessive Thyroid Hormone Ingestion Withdrawal of thyroid medications DKA Thyroid Trauma

20. Initial Therapy The therapeutic regimen should include B blocker to control symptoms caused by increased adrenergic tone Methimazole or PTU to block new hormone synthesis Steroids to reduce T4-T3 conversion

21. B Blocker Propanolol or Esmolol Propanolol 1 mg/min until adequate B Blockade is achieved Esmolol load with 250-500 ug/kg followed by an infusion at 50-100 ug/kg/min this regimen allows for more rapid titration of drugs

22. Thionamides Start blocking denovo hormone synthesis within 1-2 hours after administration Have no effect on the release of preformed hormones from the thyroid gland Methimazole has a longer duration of action PTU alone blocks T4-T3 conversion however must be given more frequently Dosages: Methimazole 30mg q6hrs PTU 200 mg q4 hours

23. Glucocorticoids Reduce T4-T3 conversion Dose Hydrocortisone 100mg IV q8

24. Our Patient Esmolol loaded and then started on Esmolol gtt at 50mcg/kg/min Methimazole 30mg q6hrs Hydrocortisone 100mg IV q8

25. Differential for Hyperthyroidism?

26. Why is our patient Hyperthyroid? Graves disease- autoimmune d/o secondary to TSI which stimulate gland growth and hormone synthesis Toxic adenoma and toxic multinodular goiter- secondary to focal and/or diffuse hyperplasia of the thyroid follicular cells Iodine load induced hyperthyroid (CT, amiodarone) Trophoblastic disease- hydatidiform mole TSH producing pituitary adenomas Thyroiditis- inflammation of thyroid, may be 2/2 chemicals (amiodarone, sunitinib), radiation, palpation (surgery) Factitious ingestion Levothyroxine overdose Struma ovarii- functioning thyroid tissue in an ovarian neoplasm

27. Additional Labs TSH <0.03 (0.4-5 mu/L) TSI 2.4 Free T3 > 12 (high) Free T4 3.55/3.25 (high) T3 total 632 (75-195 ng/dl) T4 total 20 (4.6-11.2 mcg/dl)

29. Our patient could not get the Uptake scan as she recently had a CT

30. Thyroid US Enlarged thyroid bilaterally Heterogenous with multiple ill defined low density nodules throughout Increased blood flow Most c/w thyroiditis vs multinodular goiter

31. Radioiodine Uptake Scan Essential to evaluate the etiology of hyperthyroid Patient is given a dose of radioactive iodine The iodine is concentrated into the thyroid or is excreted in the urine The amount of iodine that the thyroid uptakes is evaluated during the thyroid scan

32. Uptake Scan

33. Low radioiodine Uptake

34. Interpreting Results Hyperthyroid with high Radioiodine Uptake Graves disease Hashitoxicosis Autonomous Thyroid tissue Toxic Multinodular goiter Toxic Adenoma TSH Mediated Hyperthyroid TSH producing pituitary adenoma HCG Mediated Trophoblastic disease Hyperemesis gravidum Hyperthyroid with low Radioiodine uptake Subacute thyroiditis Granulomatous thyroiditis, lymphocyctic thyroiditis, postpartum, Amiodarone, radiation, palpation Exogenous thyroid hormone Excessive replacement therapy Factitious Ectopic Hyperthyroid Struma ovarii Metastatic follicular thyroid cancer

35. Back to our patient Transitioned from Esmolol gtt to Propanolol PO Continued Methimazole Tapered Hydrocortisone throughout hospital stay Transitioned to Moxifloxacin for treatment of PNA d/c on Lisinopril for BP control Additional antibodies were ordered and the patient was scheduled for Endocrinology appointment but failed to follow up The underlying etiology of our patient’s hyperthyroidism remained unclear

36. Take Home Points Thyroid storm is a clinical diagnosis Recognize the diagnostic criteria and the severity of the presentation The Radioiodine uptake scan is a necessary diagnostic tool for a complete evaluation of hyperthyroidism

37. References Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77. Life threatening thyrotoxicosis. Burch HB;Wartofsky L Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.Thyrotoxicosis and thyroid storm.Nayak B, Burman K. Am J Emerg Med 1991 May; 9 (3):232-4. Emergency department management of thyrotoxic crisis with esmolol. Brunette DD, Rothong C. Thyroid. 2006; 16:691. IV methimazole in the treatment of refractory hyperthyroidism. Hodak, SP, Huang, C, Clarke, D. Clin Endocrinol 1988;28:305. Comparison of methimazole, methimazole and sodium ipodate, and methimazole and saturated solution of potassium iodide in the early treatment of hypothyroidism Graves’ disease. Roti, E, Robuschi, G, Gardini, E. UpToDate. Thyroid Storm. Ross, Douglas. Am Fam. Physician. 2005 Aug;72(4):623-630. Hyperthyroidism. Diagnosis and Treatment. Reid, Jeri, Wheeler, Stephen.

38. NEW TEACHING CONFERENCE!! Join us Thursdays 2 pm for pathophysiology case conference Held in conference room next to 5th floor workroom Open to all residents and interns