Calamity averted: A case report on postoperative thyroid storm

Vol 5 | Issue 2 | May-Aug 2019 | page: 20-22 | Santhosh. V, Balaji. T, Suresh. J, Mukunthakrishnan. L

Authors: Santhosh. V [1], Balaji. T [1], Suresh. J [1], Mukunthakrishnan. L [1]

[1] Department of Anaesthesia and Critical care, Preethi institute of medical sciences and research, uthangudi, Madurai 107, India.

Address of Correspondence

Dr. Suresh.J,
Department of Anaesthesia and Critical care,
Preethi institute of medical sciences and research,
uthangudi, Madurai 107, India.
E-mail: sureshchills03@gmail.com.

Abstract

We report a case of 22yr/M admitted for knee arthroscopic procedure and medial Patello-femoral ligament repair. Postoperatively patient developed high grade fever, tachycardia, hypertension for which sepsis was suspected and relevant investigations done. Further clinical manifestations made us to think of other hyper metabolic states. Hence Thyroid function test was done which revealed thyrotoxicosis. A diagnosis of thyroid storm was made in our case according to Burch-Wartofsky score and Japanese thyroid association criteria. Patient was treated with antithyroid drugs, beta-blockers and steroids. Timely recognition and aggressive management is needed to prevent high mortality and morbidity in such cases. Mortality is as high as 10-30% even with early recognition and aggressive management.
Key words: Thyrotoxic crisis, postoperative thyroid storm, postoperative fever, hyperthyroidism

Introduction

Thyroid storm is an extreme manifestation of hyperthyroidism. It can occur in poorly treated hyperthyroidism or as an initial manifestation of undiagnosed hyperthyroidism, usually precipitated by poor drug compliance, infection, surgery or anaesthesia. Symptoms of thyrotoxicosis are caused by an excess of beta adrenergic activity which include fever, tachycardia, sweating, tremor, agitation, weight loss, arrhythmia, heart failure and can even lead to death[1]. Incidence of thyroid storm is more common 6–18 hrs post-operatively than in the intraoperative period[2]. Mortality is as high as 10-30% even with early recognition and aggressive management[3]. In our case we faced a challenge in diagnosis as there was no preoperative history or clinical features suggestive of hyperthyroidism.

Case Report

A 22 years male admitted with history of recurrent patellar dislocation with complete rupture of medial Patello- femoral ligament. Preoperative investigations and clinical examination were normal except for a squint, which was evaluated at 4 years of age. He was taken up for diagnostic knee arthroscopy and repair of medial Patello-femoral ligament under spinal anaesthesia. Intraoperative period was uneventful. 4 Hours after surgery patient developed high grade fever (103o F), tachycardia (130/min), hypertension (180/100 mm hg) along with severe pain over surgical site for which he was treated with titrated IV opioids, NSAIDS, Antipyretics and other cooling measures. There was no blood loss or dehydration to account for tachycardia. He had high grade fever, tachycardia and severe pain over surgical site on first Post operative day too. Epidural analgesia was initiated and pain reduced significantly. But tachycardia (140-160/min) and fever spikes (103 F) persisted. Inflammatory markers with blood and wound cultures were done. Antibiotics escalated to carbapenems in view of high index of suspicion of sepsis as per our hospital antibiotic protocol. On 2nd post-operative day patient had nausea, vomiting , altered sensorium (restlessness, disorientation). There were no clinical signs of meningism. CT brain was done, found to be normal. Patient had evolving clinical manifestations with increase in severity and the persistence of the symptoms made us to think of other hyper metabolic states. A blood sample for thyroid function test was sent which revealed severe hyperthyroidism. A diagnosis of thyroid storm was made according to the Burch- Wartofsky score 4.Our patient had a score of 80 which is highly suggestive of thyroid storm. According to Japan thyroid association definition and diagnostic criteria for thyroid storm5 our patient comes under TS1- definitive thyroid storm. Endocrinologist opinion obtained, patient was started on T. carbimazole 20 mg BID, T. Propranolol 40 mg TID and IV dexamethasone 4 mg BID with adequate hydration. Patient showed gradual symptomatic improvement. Follow up Thyroid function test revealed decrease in T3 and T4 levels. Patient was discharged on 10th Post-operative day with anti thyroid medications. After 15 days patient came for follow up, thyroid function test revealed decreasing trend of T3, T4 levels. Dosage adjusted to T. Carbimazole 20 mg TID after endocrinologist review.

Discussion

Thyroid storm is a life threatening manifestation of hyperthyroidism due to excessive amount of circulating thyroid hormones. We report a case of 22 years old male who had Post-operative thyroid storm. In a recent manuscript thyroid storm is estimated to be 0.2 persons/ 1, 00,000 population / year, accounting for 0.22% of all thyrotoxic patients [6]. The diagnosis of thyroid storm is made clinically based on a constellation of signs and symptoms. Though Burch-Wartofsky score gives a likelihood that the patient has thyroid storm, it’s not a definitive criteria. Our patient had BurchWartofsky score of 80 which indicates very high likelihood of thyroid storm. Akamizu et al reviewing the most common clinical presentations of thyroid storm in Japanese patients suggested that different combinations of symptoms that could categorize a patient as having definitive versus suspected storm. According to Japanese thyroid association criteria, our patient was labelled as TS [1]. In a survey of Japanese patients with thyroid storm, the leading cause of death include multiorgan failure (24%) and congestive heart failure (21%)[7]. The most common cause leading to thyroid storm were irregular or discontinuation of treatment followed by infection [8]. Due to adherence of anti thyroid drugs and good pre op preparation of thyrotoxicosis patients there is a drastic decrease in surgical cause of thyroid storm. In our case the primary presentation was itself thyroid storm. Perioperative period made it further difficult to diagnose, as there are overlapping of symptoms of other conditions which occurs more commonly in the post operative period. The presence of CNS manifestations with fever, tachycardia along with thyrotoxicosis helped us in confirming our diagnosis of thyroid storm. According to Japanese thyroid association, treatment strategies involves control of systemic symptoms and signs, control of thyrotoxicosis, control of organ specific manifestations, identification and treatment of thyrotoxicosis, definitive therapy of thyrotoxicosis Pharmacological therapy involves anti thyroid drugs, beta blockers, corticosteroids, inorganic iodide and antipyretic agents. Though propylthiouracil (PTU) was preferred drug earlier [9], there are no differences in mortality between patients treated with PTU and methimazole [ 1 0 ]. In organiciodide should be administered along with anti thyroid drugs in patients with thyroid storm which reduces blood flow to thyroid gland and blocks the re l ea s e of thy roid hormone s [11]. Hyperdynamic state and sympathomimetic symptoms related to excessive thyroid hormones should be treated with beta blockers. Beta 1 selective drugs such as landiolol, esmolol, bisoprolol are preferred than non-selective beta blockers for treatment of tachycardia. Propranolol without landiolol showed increased mortality in patients with congestive cardiac failure. Though not contraindicated use of non- selective beta blockers particularly Propranolol requires caution [12]. Glucocorticoids such as hydrocortisone or dexamethasone not only decrease peripheral conversion of T4 to T3, but also help prevent adrenal insufficienc y due to severe thyrotoxicosis and improve vasomotor symptoms [13, 14]. Plasmapheresis can be used as a rescue treatment to remove thyroid hormones, catecholamine and cytokines if conventional medical treatments are ineffective or contraindicated [15].

Conclusion

Through very rare thyrotoxicosis can present as thyroid storm as an initial manifestation. Perioperative period being a highly stressful one, may act as a trigger for thyroid storm. Apart from sepsis, thyroid storm may also be considered as differential diagnosis, if associated with CNS and GI symptoms.

References

1. Braverman L, Utiger R. In: The Thyroid. 9th ed. Braverman L, Utiger R, editors. Philadelphia: Lippincott Williams & Wilkins; 2005. Introduction to thyrotoxicosis; pp. 453–455.
2. Bennett MH, Wainwright AP. Acute thyroid crisis on induction of anaesthesia. Anaesthesia. 1989;44:28–30.
3. Ono Y1, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan Medicine (Baltimore). 2016 Feb;95(7):e2848.
4. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993;22(2):263–277
5. Takashi Akamizu Thyroid Storm: A Japanese Perspective thyroid 2018 Jan 1; 28(1): 32–40
6. Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. official journal of the American Thyroid Association.
2012;22(7):661-79
7. Scholz GH, Hagemann E, Arkenau C, Engelmann L, Lamesch P, Schreiter D, Schoenfelder M. et al. Is there a place for thyroidectomy in older patients with thyrotoxic storm and cardiorespiratory failure? Thyroid. 2003;13(10):933 940.
8. Nqo SY, Chew HC. When the storm passes unnoticed – a case series of thyroid storm. Resuscitation 2007; 73 (3): 485-90
9. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 26:1343–1421
10. Vydro L, Joglekar S, Sheh S, Yau H, Naing S. 2015. Choice of antithyroid drugs and the outcome of patients with thyroid storm. 15th International Thyroid Congress, Orlando, FL
11. Ansaldo GL, Pretolesi F, Varaldo E, Meola C, Minuto M, Borgonovo G, Derchi LE, Torre GC. Doppler evaluation of intrathyroid arterial resistances during preoperative treatment with Lugol’s iodide solution in patients with diffuse toxic goiter.J Am Coll Surg. 2000 Dec;191(6):607-12.
12. Satoh T, Isozaki O, Suzuki A, Wakino S. Guidelines for the management of thyroid storm from the japan thyroid association and japan endocrine society. Endocrine Journal. 2016;63(12):1025-64.
13. Bianco AC, Nunes MT, Hell NS, et al. The role of glucocorticoids in the stress-induced reduction of extrathyroidal 3,5,3’-triiodothyronine generation in rats. Endocrinology 1987;120:1033-8. 10.1210/endo-120-3-
1033
14. Tsatsoulis A, Johnson EO, Kalogera , Seferiadis K, Tsolas . The effect of thyrotoxicosis on adrenocortical reserve. Eur J endocrinol. 2000;142(3):231–235
15. Muller C1, Perrin P, Faller B, Richter S, Chantrel F. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec; 15(6):522-3

How to Cite this Article: Santhosh. V, Balaji. T, Suresh. J, Mukunthakrishnan. L. Calamity averted: a case
report on postoperative thyroid storm. Journal of Anaesthesia and Critical Care CaseReports May-Aug 2019; 5(2):20-22.