2000 Associates' Presentations
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Thyroid Crisis Presenting in a Young Male
Richard Warshell, MD, Sinai Samaritan Medical Center, Milwaukee, WI
Introduction: Thyrotoxicosis is caused by excessive circulating levels of thyroid hormone. The presentation may be confusing because complaints are non-specific and vague. The condition affects all organ systems. Patients may complain of "not feeling well," fatigue, restlessness, irritability, shortness of breath and/or weight loss. Physical examination may not be helpful unless careful attention is paid to the thyroid gland, which is invariably enlarged. Untreated thyrotoxicosis can lead to thyroid crisis.
Case: A 31-year-old African-American male with no significant past medical history complained of fatigue, weakness, shortness of breath, constipation, and a 25 pound weight loss over the past month. Physical examination showed a well-nourished African-American male in no acute distress. He was afebrile, normotensive, and had a pulse of 125. There was no palpable goiter. The rest of the examination was normal. Laboratory work-up revealed normal electrolytes and blood counts. EKG showed sinus tachycardia. The only abnormality noted was an elevated serum calcium of 12.5 mg/dl. The patient was admitted to a general medical bed with telemetry. The following day his temperature rose to 39º and his heart rate increased to 150. He complained of chest pain and shortness of breath. TSH drawn on admission came back less than 0.01 IU/ml and free T4 was 5.3ng/dL. He was immediately treated for thyroid crisis with propanolol 80 mg tid and PTU 100 mg tid. Within two days his symptoms had much improved and he was discharged home.
Discussion: Thyroid crisis is a rare but serious complication of thyrotoxicosis. Untreated, it is invariably fatal - even with treatment the mortality rate is 20%. Patients need to be monitored closely and therapy started immediately. The crisis results from a hypermetabolic state caused by excessive circulating thyroid hormone. Validated criteria, based on a point system has been published to distinguish simple thyrotoxicosis from thyroid crisis. Patients in crisis are frequently febrile and tachycardic. Hypercalcemia is present in 27% of the patients. Treatment includes supportive measures, beta adrenergic blockade and drugs to interrupt the synthesis of thyroid hormone.
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