The objective of this report was to emphasize the early recognition of thyrotoxicosis in the assessment of a pediatric patient with tachycardia. We present here the case of a 17-year-old female who presented with supraventricular tachycardia and was found to be in a state of severe thyrotoxicosis with borderline features of a thyroid storm.
Trang 1AACE CLINICAL CASE REPORTS Vol 5 No 6 November/December 2019 e393
Copyright © 2019 AACE
Case Report
THYROTOXICOSIS IN A PEDIATRIC PATIENT WITH SUPRAVENTRICULAR TACHYCARDIA AND BORDERLINE FEATURES OF THYROID STORM
Manthan Pandya, MD; R Angel Garcia, DO; Jeremy Awori, MD
Submitted for publication June 2, 2019
Accepted for publication August 26, 2019
From Trinitas Regional Medical Center, Division of Internal Medicine,
Elizabeth, New Jersey.
Address correspondence to Dr Manthan Pandya, Trinitas Regional Medical
Center, Department of Internal Medicine, 225 Williamson Street, 4th Floor
Cancer Center, Elizabeth, NJ 07202.
E-mail: manp1490@gmail.com
DOI: 10.4158/ACCR-2019-0261
To purchase reprints of this article, please visit: www.aace.com/reprints.
Copyright © 2019 AACE.
ABSTRACT
Objective: The objective of this report was to
empha-size the early recognition of thyrotoxicosis in the
assess-ment of a pediatric patient with tachycardia We present
here the case of a 17-year-old female who presented with
supraventricular tachycardia and was found to be in a
state of severe thyrotoxicosis with borderline features of a
thyroid storm
Methods: A 17-year-old African American female
presented to the hospital with complaints of nausea,
vomiting, and diarrhea associated with palpitations for
1 week Initial workup included electrocardiogram, total
blood count, lipase, basic metabolic panel, and thyroid
function tests
Results: Initial vital signs were significant for a
temperature of 100.1ºF, and tachycardia with a heart rate
(HR) of 180 beats per minute (bpm) Initial telemetry
was significant for supraventricular tachycardia with a
HR of 180 bpm Vagal maneuvers including carotid sinus
massage were attempted first followed by 6 mg
intrave-nous (IV) push and then 12 mg IV push of adenosine
However, the patient remained tachycardic with a HR in
the 150s Laboratory evaluation confirmed the presence of
thyrotoxicosis with a thyroid-stimulating hormone of 0.17
µIU/mL (normal, 0.5 to 4.7 µIU/mL) with a free thyroxine
of 4.90 ng/dL (normal, 0.8 to 2.0 ng/dL) and free triiodo-thyronine >20 pg/mL (normal, 1.95 to 5.85 pg/mL) She was subsequently treated with propranolol, methimazole, and hydrocortisone, which resolved her symptoms in a few hours
Conclusion: Due to high mortality rates, severe
thyro-toxicosis needs to be recognized and treated early This case report highlights the importance of early recognition
of thyrotoxicosis in the initial management of tachycardia
in the pediatric population (AACE Clinical Case Rep
2019;5:e393-e395) Abbreviations:
BPM = beats per minute; BWPS = the Burch-Wartofsky
Point Scale; T3 = triiodothyronine; T4 = thyroxine; TS
= thyroid storm
INTRODUCTION
Thyroid storm (TS), is a serious, life threatening complication of thyrotoxicosis TS diagnosis must be made based on suspicion of nonspecific clinical findings Typically, TS is associated with some underlying thyroid disease, whether it be Graves disease, adenomas, or in some cases following thyroidectomy Early recognition and management are key as thyroid storm carries a high mortality rate TS can be missed, especially in patients with no known prior history of hyperthyroidism and atypi-cal presentations For example, the most common rhythm disturbance in hyperthyroid states is sinus tachycardia, with atrial fibrillation and less common forms of supraven-tricular tachycardia ranging only from 2 to 20% (1) Here
we report the case of a 17-year-old female with no known history of thyroid disease, who presented with severe thyrotoxicosis manifested as supraventricular tachycardia
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CASE REPORT
Our case is a 17-year-old, African American female
with no significant past medical history who presented
with complaints of nausea and vomiting, diarrhea, and
palpitations for 1 week She denied any history of weight
changes, chest pain, skin changes, menstruation changes,
sore throat, neck swelling, sick contacts, or recent travel
She denied any prior history of similar symptoms
Upon initial presentation in the emergency
depart-ment, the patient had a fever of 100.1ºF and was
tachy-cardic at 180 beats per minute (bpm) Physical examination
was otherwise unremarkable, with no signs of goiter,
cervi-cal lymphadenopathy, exophthalmos, or pretibial
myxede-ma Initial blood work, including complete blood count,
beta human chorionic gonadotropin, lactic acid, troponin,
lipase, and serum chemistry, were all normal Thyroid
function tests were also ordered Telemetry showed the
presence of a narrow complex tachycardia, suggestive of
supraventricular tachycardia at a heart rate of 180 bpm
Vagal maneuvers such as carotid sinus massage were
attempted; however, the patient remained tachycardic She
then received one 6 mg intravenous (IV) push of
adenos-ine, followed by another IV push of 12 mg of adenosine
However, the patient continued to remain tachycardic
An electrocardiogram obtained at this time showed
sinus tachycardia with heart rate persistently elevated at
150 bpm Subsequently, thyroid function tests showed a
thyroid-stimulating hormone of 0.17 µIU/mL (normal,
0.40 to 4.50 µIU/mL), with a free thyroxine (T4) of 4.90
ng/dL (normal, 0.8 to 1.6 ng/dL), and a free
triiodothyro-nine (T3) >20 pg/mL (normal, 3.0 to 4.7 pg/mL) Thyroid
ultrasound was significant for an enlarged, heterogeneous,
and hypervascular gland, consistent with an autoimmune or
inflammatory thyroiditis (see Fig 1) suggestive of Graves
disease Additionally, thyroid peroxidase antibodies were
also ordered which were found to be elevated at 312 IU/mL
(normal, <20 IU/mL)
The patient was subsequently treated with
proprano-lol 40 mg, methimazole 20 mg, and hydrocortisone 100
mg Following this treatment, her tachycardia gradually
resolved in a span of a few hours She was then transferred
to a pediatric intensive care unit, where her symptoms
gradually resolved, and she was discharged the following
day on a stable dose of methimazole with outpatient
endo-crinology follow-up
DISCUSSION
TS without prior history of thyroid disease or a
precipitating event is rare in the pediatric population,
with no documented incidence rate in the United States
(2) Children constitute less than 5% of all
thyrotoxico-sis cases, and most cases commonly occur as a result of
Graves disease which is only seen in 0.2 to 0.4% of the
pediatric and adolescent population (3) Delayed treatment
or if left untreated, the mortality rate of thyroid storm in adults is 90% and likely to have similar severe outcomes
in children Hence, early recognition of thyroid storm
is crucial
There have been several approaches towards diagnos-ing TS For example, the Burch-Wartofsky Point Scale (BWPS), published in 1993, identifies TS by ranking typi-cal features of end organ dysfunction (3) Features such as fever, tachycardia, and central nervous system symptoms receive a score based on severity Evidently, the problem with this system is the absence of thyroid function tests in the criteria Hence, a patient in “severe sepsis” or “septic shock” could be diagnosed with a thyroid storm if the BWPS criteria are used Alternatively, in 2012, the Japan Thyroid Association published its own set of criteria for diagnosing TS (4) These criteria require the prerequisite
of thyrotoxicosis manifested as an elevated T3 and T4 combined with other objective data (4) Our patient met a score of 45 on the BWPS criteria (definitive thyroid storm) and a stage TS2 on Japanese criteria, which was highly suggestive of a thyroid storm
It was initially difficult to postulate whether her abdominal symptoms and arrhythmia (supraventricular tachycardia) were secondary to a hyperthyroid state Of note, studies have consistently demonstrated that up to 90% of supraventricular tachycardias terminate within
30 seconds when 2 or more doses of adenosine are used (5) It was the lack of response to adenosine and results of thyroid function tests which eventually guided appropriate management
Common triggers for TS include improper use of medication, infection, trauma (sexual assault), radioiodine therapy, intense exercise, teeth extraction, and diabetic ketoacidosis On initial presentation, the possibility of a gastrointestinal infection was entertained However, the patient had a normal white blood cell count and a normal lactic acid level Notably, the results of the thyroid
ultra-Fig 1 Ultrasound demonstrating an enlarged, heterogeneous, and
hyper-vascular thyroid gland
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Copyright © 2019 AACE
sound and elevated antithyroid peroxidase antibody
levels did unmask an underlying autoimmune thyroiditis;
possibly Graves disease
Once a thyroid storm is recognized, the main goal
and best initial therapeutic option is best outlined as the
5Bs: block synthesis with an antithyroid drug
(methima-zole), block release, typically with iodine, block T4 to T3
conversion (propylthiouracil, propranolol, or
corticoste-roids), beta-blockers (propranolol), and block
enterohe-patic circulation (cholestyramine) (6) On rare occasions,
if the thyroid storm is refractory to medical treatment,
thyroidectomy could be curative Our patient was started
on methimazole, beta blockers, and steroids to which she
responded and her symptoms gradually abated
CONCLUSION
Thyroid storm is a critical endocrine emergency that
can be fatal if not diagnosed and treated in a timely manner
Since symptoms and signs can vary, there should be a high
index of suspicion even in patients with no prior history of
thyroid disease and atypical presentations This case report
highlights the importance of early recognition of
thyro-toxicosis in patients who may present with supraventricu-lar tachycardia to guide prompt management and prevent morbidity and mortality associated with thyroid storm
DISCLOSURE
The authors have no multiplicity of interest to disclose
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