Category: Thyroid

Monitor: 31

31 - Thyroid storm in an HIV patient: a late manifestation of immune reconstitution syndrome

Saturday, Apr 27
11:00 AM – 11:30 AM

Objective :

Thyroid storm is a rare and fatal endocrine emergency with an reported mortality rate of 10-20%. With a growing number of patients obtaining access to HIV medications, anticipating immune reconstitution inflammatory syndrome (IRIS) is critical in prevention of serious autoimmune complications.


Methods : N/A


Results : N/A


Discussion : A 48-year-old Hispanic female with HIV on efavirenz/emtricitabine/tenofovir, toxoplasmosis, intracranial hemorrhage with residual left hemiparesis, and depression presented to the emergency department due to a 2-week history of agitation and confusion. She has been compliant with her HIV medications since she was diagnosed in 2012. On physical examination, she was tremulous and distressed. Vital signs: BP 143/79 mmHg, PR 131, RR 26, and temperature 99.1°F. She had visual fixation, lid lag, and mild thyroid enlargement. She had residual left hemiparesis and contractures from her previous stroke, as well as, myoclonus in the left upper and lower extremities. CBC and electrolytes were within normal limits. AST 47 (8-20 U/L), ALT 22 (8-20 U/L), LDH 332 (45-90 U/L) and alkaline phosphatase 358 (20-70 U/L). CD-4 count was 376.9 (689-1,566/mm3), HIV viral load 2000 (230-420 pg/dL), free T4 5.15 (0.7-1.6 ng/dL), and T4 28.9 (5-11 mcg/dL). Her Burch-Wartofsky score was >45 which was consistent with thyroid storm. Review of her previous records showed that she was started on HAART therapy three years ago with a CD-4 count of 30.9 (689-1,566/mm3) and HIV viral load RNA PCR of 137,376. She was started on methimazole 30 mg, propranolol 60 mg, and hydrocortisone 100 mg. After several hours, patient improved. Heart rate was controlled; she was less agitated and more coherent. She was discharged improved and stable.


Conclusion :

The exact pathogenesis of IRIS is complex and unclear. Pre-existing autoimmune disease, acquired defects in immune tolerance, and restoration of immune response may induce susceptibility to autoimmune diseases such as thyroid storm after initiation of HAART. Screening for thyroid disorder is suggested in patients with thyroid-related or with non-specific systemic symptoms. However, there is no evidence to support routine screening in all HIV patients. Physician awareness and understanding of this treatment complication may aid in prevention, early detection, and treatment such serious autoimmune complications.

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Mark Anthony Diaz

Infectious Disease Fellow
Mayo Clinic

B.S., Ateneo de Manila University (Quezon City, Philippines), Completion 2006
M.D., University of Santo Tomas (Manila, Philippines), Completion 2011
2011-2012 Postgraduate Internship Training, University of Santo Tomas Hospital (Manila, Philippines)
2014-2017 Internal Medicine Residency, Monmouth Medical Center (Long Branch, New Jersey)
2017-present Infectious Disease Fellowship, Mayo Clinic (Jacksonville, Florida)

Marie Angelica Landicho

Endocrinology Fellow
University of Florida College of Medicine - Jacksonville
Jacksonville, Florida

Ateneo de Manila University (Quezon City, Philippines), B. S., Completion in 2007
University of Santo Tomas (Manila, Philippines), M. D., Completion in 2011
2011-2012 Postgraduate Internship Training, University of Santo Tomas Hospital (Manila, Philippines)
2014-2017 Internal Medicine Residency, Monmouth Medical Center (Long Branch, New Jersey)
2017-present Endocrinology Fellowship, University of Florida College of Medicine – Jacksonville (Jacksonville, Florida)

Chandni Merchant

Internist
Willamette valley medical center
McMinnville, Oregon

I am an internist practicing out patient internal medicine in oregon, employed by a community hospital. I have string onterests in endocrinology . Currently, majority of my practice is medicare,/ geriatrics patients.

Margaret Eng

Program Director, Department of Medicine
Monmouth Medical Center

SUNY Health Science Center at Brooklyn, Residency , Internal Medicine
University of Maryland, Fellowship , Infectious Disease
Albert Einstein College of Medicine of Yeshiva University, Medical School

Mark Anthony Diaz