Objective : Thyroid storm is a serious condition that can be rapidly fatal if untreated. It is usually associated with under or untreated hyperthyroidism. Typical signs and symptoms include thermoregulatory, cardiovascular, and central nervous system dysfunction. We present a case of thyroid storm with an atypical presentation of dyspnea and diarrhea. The case demonstrates the importance of prompt diagnosis and treatment, as well as continued therapy, for favorable outcomes.
Methods : N/A
Results : N/A
Discussion : A 47 year-old female with past medical history of HIV/AIDS, hyperthyroidism, sickle cell trait, diastolic heart failure, and recent history of Clostridium difficile colitis presented to the ED with fever, dyspnea, and a cough productive of yellow sputum for one week. Symptoms had progressed to where she is unable to complete her regular activities. She denied nausea or vomiting, but endorsed nonbloody diarrhea for the past six months. She lost about twenty pounds, despite an increased appetite. She was started on prophylactic trimethoprim-sulfamethoxazole within the last month due to a CD4 count of 115 cells/µL; her HIV-regimen was switched to darunavir, ritonavir, lamivudine, abacavir, and dolutegravir. She was treated for hyperthyroidism in the past with methimazole, but stopped taking it one year ago. She was compliant with all other medications. Vital signs on admission demonstrated hyperthermia (38.4°F), tachycardia (140 beats/min), tachypnea (22 respirations/min), normal pulse oximetry (SaO2 100% on room air), and hypertension (224/117 mmHg). Infectious workup revealed unremarkable blood cultures and stool analysis, and respiratory viral panel was positive for rhinovirus. TSH was undetectable, with markedly elevated free T3 (>20.0 pg/mL), and free T4 (5.8 ng/dL). Patient was transferred to the medical step down unit and promptly treated with methimazole, propranolol, and hydrocortisone. After five days, her symptoms improved, and by day seven, her TFTs normalized. Surgical thyroidectomy was recommended at discharge.
Conclusion : Thyroid storm is a rare, yet life threatening condition that usually presents with hyperthermia, tachycardia, and elevated blood pressure. Symptoms can also include agitation, seizure, abdominal pain, decompensated heart failure, and atrial fibrillation. Our patient presented with dyspnea and chronic diarrhea in the setting of HIV/AIDS, which prompted us to initially start an infectious workup. The diagnosis of thyroid storm remains a clinical diagnosis, and timely treatment is necessary to decrease morbidity and mortality. This case demonstrates how patients with a complicated medical history can exhibit atypical symptoms, often leading to delayed diagnoses.
Khwaila Falaneh– Internal Medicine Resident, University of Ilinois at Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois
Matthew Mandell– Internal Medicine Resident Physician, University of Illinois at Chicago/Advocate Christ Medical Center, Chicago, Illinois
Armand Krikorian– Program Director, Internal Medicine, University of Illinois at Chicago/Advocate Christ Medicine, Oak Lawn, Illinois
Internal Medicine Resident
University of Ilinois at Chicago/Advocate Christ Medical Center
Oak Lawn, Illinois
Khwaila Falaneh is a first year internal medicine resident at UIC/Advocate Christ Medical Center.
Internal Medicine Resident Physician
University of Illinois at Chicago/Advocate Christ Medical Center
Matthew Mandell is a second-year internal medicine resident at UIC/Advocate Christ Medical Center.