Report of a rare case of trauma-induced thyroid storm. (Original Article).

Abstract

Thyroid storm is a potentially life-threatening endocrinologic emergency characterized by an exacerbation of a hyperthyroid state. Several inciting factors can instigate the conversion of thyrotoxicosis to thyroid storm; trauma is one such trigger, but it is rare. Patients with thyroid storm can manifest fever, nervous system disorders, gastrointestinal or hepatic dysfunction (e.g., nausea, vomiting, diarrhea, and/or jaundice), and arrhythmia and other cardiovascular abnormalities. Treatment of thyroid storm is multimodal and is best managed by the endocrinologist and medical intensivist. Initial medical and supportive therapies are directed at stabilizing the patient, correcting the hyperthyroid state, managing the systemic decompensation, and treating the underlying cause. Once this has been achieved, definitive treatment in the form of radioactive ablation or surgery should be undertaken. We describe a case of thyroid storm in a young man that was precipitated by a motor vehicle accident.

Introduction

Thyroid storm (crisis) is an endocrinologic emergency characterized by an exacerbation of a hyperthyroid state. Unrecognized or untreated, it can be fatal. Despite advances in the diagnosis and treatment of thyroid crisis, mortality remains high, ranging between 20 and 30%. (1) In this article, we describe the case of a young man who experienced thyroid storm following a motor vehicle accident.

Case report

A 21-year-old man was brought to the emergency department by air transport following a motor vehicle accident in which he was the driver of one of the vehicles. The patient had not worn a seat belt, and he was found ejected from his vehicle at the scene of the accident.

Upon admission, the patient was combative. While performing the primary and secondary surveys, the trauma service noted that the patient's neck was swollen anteriorly. Doppler ultrasonography detected an enlarged heterogeneous thyroid gland and an associated hematoma. Magnetic resonance imaging (MRI) performed for cervical spine clearance revealed similar findings (figure 1). The otolaryngology service was consulted. The patient had several facial fractures and lacerations, and an edematous ecchymotic anterior neck with a bruit on auscultation. He also exhibited sinus tachycardia, with a pulse rate that ranged between 125 and 167 beats per mm. His temperature was 101.5[degrees] F (38.6[degrees] C), and he was extremely agitated.

Findings on thyroid testing were abnormal. Our laboratory reported that the patient's serum thyroxine ([T.sub.4]) level was greater than 23 [micro]g/dl (normal: 4 to 12), his free [T.sub.4] level was 5.73 ng/dl (normal: 0.7 to 1.8), his triiodothyronine ([T.sub.3]) level was greater than 600 ng/dl (normal: 90 to 240), and his thyroid-stimulating hormone (TSH) level was less than 0.01 [micro]U/ml (normal: 0.3 to 5). An endocrinology consultation was obtained for management of thyroid storm, and the patient was started on methimazole, ipodate, and an esmolol drip.

Over the next several days, the patient's tachycardia abated and his thyroid levels began returning to normal (figure 2). The esmolol drip was discontinued and the patient was started on an oral beta blocker; the ipodate was eventually stopped. Further discussion with the patient and his mother revealed that he had a 1-month history of weight loss, increased appetite, diarrhea, nervousness, tremors, and insomnia, which taken together suggested that the patient had been in a thyrotoxic state prior to his accident.

Discussion

The clinical features of thyroid storm can be described as an exaggeration of an uncomplicated thyrotoxic state. Hyperthyroid patients often complain of heat intolerance, diaphoresis, palpitations, restlessness, and anxiety. During thyroid storm, these relatively benign symptoms can worsen and become life-threatening.

One of the most striking features of thyroid storm is hyperpyrexia, as temperatures have been reported to reach as high as 108.3[degrees]F (42.4[degrees] C). (2) The central nervous system is often affected, and patients might experience anxiety, confusion, severe delirium, agitation, and psychosis. (1) Nausea, vomiting, diarrhea, and even frank jaundice might ensue. From a cardiovascular standpoint, sinus tachycardia and increased systolic blood pressure are common; atrial and ventricular tachyarrythmias and associated ventricular dysfunction and high-output congestive heart failure have also been reported. (3) Physical examination of the patient's neck often reveals the presence of an enlarged thyroid gland with a bruit or palpable thrill. (4)

Distinguishing between thyrotoxicosis and thyroid storm can be difficult. Laboratory tests can be helpful, but ultimately the diagnosis must be made clinically. Several studies have revealed that patients with thyroid storm have elevated [T.sub.4], free [T.sub.4], and [T.sub.3] levels. (3) However, waiting for laboratory results can delay treatment and cause unnecessary morbidity. To overcome this obstacle, Burch and Wartofsky developed a rating scale that helps differentiate among uncomplicated thyrotoxicosis, impending thyroid storm, and established thyroid storm (table). (3)

Patients with thyroid storm frequently have a long history of symptoms consistent with a hyperthyroid state before the onset of the crisis. Most authors agree that a precipitating event or illness is responsible for most conversions from thyrotoxicosis to thyroid storm. Among the most common precipitating factors are radioiodine therapy, injection of iodinated contrast dye, infection, diabetic ketoacidosis, cerebrovascular accident, pulmonary embolism, pregnancy, stress, and trauma. (1) At onetime, thyroid surgery was the most common inciting factor, but it rarely is today because we now medically induce a euthyroid state prior to surgery. Trauma as an inciting event is also rare; prior to the publication of this report, only three other cases had been reported in the English-language literature. (5-7)

Treatment of thyroid storm is multimodal and is best managed by the endocrinologist and medical intensivist. Supportive therapies such as intravenous hydration, oxygen, pressor agents (in the event of circulatory collapse), electrolyte correction, arrhythmia management, and aggressive reversal of hyperthermia should be delivered promptly. Medical therapy is directed at stabilizing the patient, correcting the hyperthyroid state, managing the systemic decompensation, and treating the underlying cause. In general, management of the hyperthyroid state can be accomplished by (1) reducing thyroid hormone production with propylthiouracil or methimazole, (2) inhibiting thyroid hormone release with iodine or lithium, and (3) reducing peripheral conversion of [T.sub.4] to [T.sub.3] with propylthiouracil, steroids, propranolol, or ipodate. (3)

After the patient has been stabilized, definitive treatment in the form of radioactive ablation or surgery should be undertaken; until then, patients should be continued on antithyroid medications and a beta blocker. In most situations, radioactive iodine ablation cannot be used for several months following thyroid storm because of the high doses of iodine that are required during the acute phase of management. Subtotal thyroidectomy, on the other hand, can be performed much sooner, but keep in mind that a recurrent thyroid crisis can occur if the thyrotoxic state is not well controlled.

[FIGURE 2 OMITTED]

Table. Diagnostic criteria (point scale *) for thyroid storm +

Thermoregulatory dysfunction             Points

Body temperature ([degrees] F)
         99.0 to 99.9                      5
        100.0 to 100.9                     10
        101.0 to 101.9                     15
        102.0 to 102.9                     20
        103.0 to 103.9                     25
        [greater than or equal to]104.0    30

Central nervous system effect

Absent                                     0
Mild (agitation)                           10
Moderate (delirium, psychosis,             20
 extreme lethargy)
Severe (seizure, coma)                     30

Gastrointestinal or hepatic dysfunction

Absent                                     0
Moderate (diarrhea, nausea,                10
 vomiting, abdominal pain)
Severe (unexplained jaundice)              20

Cardiovascular dysfunction

Tachycardia (beats per min)
        90 to 109                          5
       110 to 119                          10
       120 to 129                          15
       130 to 139                          20
       [greater than or equal to]140       25

Congestive heart failure
            Absent                         0
            Mild (pedal edema)             5
            Moderate (bibasilar rales)     10
            Severe (pulmonary edema)       15

Atrial fibrillation
            Absent                         0
            Present                        10

Precipitant history

Negative                                   0
Positive                                   10

* A point total of [greater than or equal to]45 is highly suggestive of
thyroid storm, a score of 25 to 44 is suggestive of impending storm, and
a score of [less than or equal to]24 suggests that thyroid storm is
unlikely.

+ Adapted from Burch and Wartofsky. (3)

References

(1.) Tietgens ST, Leinung MC. Thyroid storm. Med Clin North Am 1995;79:169-84.

(2.) Nelson NC, Becker WF. Thyroid crisis: Diagnosis and treatment. Ann Surg 1969;170:263-73.

(3.) Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263-77.

(4.) Gavin LA. Thyroid crises. Med Clin North Am 1991;75:179-93.

(5.) Yashida D. Thyroid storm precipitated by trauma. J Emerg Med 1996;14:697-701.

(6.) Jacobs RR. Acute hyperthyroidism precipitated by trauma. South Med J 1979;72:890-1.

(7.) Gregg-Smith SJ. Thyroid storm following chest trauma. Injury 1993;24:422-3.

From the Division of Otolaryngology-Head and Neck Surgery, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey.

Reprint requests: Brendan C. Stack Jr., MD, Division of Otolaryngology-Head and Neck Surgery, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, PO Box 850, Hershey, PA 17033. Phone: [phone]; fax: [phone]; e-mail: [e-mail]