THYROID STORM MIMICKING INTRA-ABDOMINAL SEPSIS IN A YOUNG FEMALE

Pranjali Sharma, MD*1;Nabeel AlQsous, MD2;Yogeeta V Naidu, MD3;Mathhar Aldaoud, MD4 and Ingrid Wohlgemuth, MD1, (1)Unity Hospital, Rochester Regional Health, ROCHESTER, NY, (2)Unity Hospital, rochester, NY, (3)Rochester Regional Health, Rochester, NY, (4)Unity Health System, Rochester, NY

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract number: 718

Categories: Adult, Clinical Vignette Abstracts, Finalist Poster

Keywords: ,

Case Presentation: A 38 year old lady with past medical history of recurrent kidney stones presented to the emergency department with a 1 day history of lethargy, confusion, and severe right sided abdominal pain. She was febrile with temperature of 38.9oC and tachycardic with heart rate of 168 bpm. She had leukocytosis of 13,000/ml and lactic acid of 63.3 mg/dL (normal 0-19 mg/dl). A clinical diagnosis of acute abdomen was made. CT abdomen was unremarkable for obstruction or perforation. It showed stable bilateral nephrolithiasis, unchanged from prior imaging. Urinalysis was negative for any hematuria or signs of infection. Broad spectrum antibiotics and IV crystalloids were begun for presumed sepsis due to an intra-abdominal pathology.

Worsening confusion and tachycardia (heart rate >180 bpm) prompted ICU consultation and further evaluation. Although the patient did not have overt signs of an underlying thyroid disorder, (exophthalmos, lid lag, goiter), laboratory work confirmed the suspicion of thyroid storm with TSH of <0.1 uIU/ml (normal 0.35-5.50 uIU/ml), T3 of 783.7 ng/dl (normal 60-181 ng/dl), and free thyroxine of 5.8 ng/dl (normal 0.9-1.8 ng/dl). Propranolol and Methimazole were begun. Final cultures were negative and antibiotics were discontinued. Patient’s symptoms resolved with the above treatment and her thyroid functions improved (T3 447.2 ng/dl, Free T4 4.6 ng/dl). Her leukocytosis and lactic acidosis resolved.  Further immunological work-up revealed an undiagnosed Graves’ disease with high titres of Anti-TSH antibodies. 

Discussion: Thyroid storm is a decompensated state of thyrotoxicosis with a reported fatality rate of 20-30%. Recognition of thyroid storm can be difficult, because signs and symptoms are non-specific, as seen in the above patient. It may mimic other severe illness such as acute abdomen. Our patient did not have a history of thyroid disease or typical examination findings of hyperthyroidism.

Abdominal pain of recent onset can be a challenging clinical problem. The triad of fever, abdominal pain and confusion should be fully evaluated for intra-abdominal sepsis due to bacterial contamination or chemical irritation, mechanical obstruction of hollow viscera, vascular disturbances such as embolism or thrombosis, as well as metabolic causes such as diabetic ketoacidosis and thyroid storm.

Conclusions:

  1. Thyroid storm should be considered in the differential diagnosis of patients presenting with acute abdomen and signs of sepsis.
  2. Any patient presenting with fever, tachycardia and confusion needs prompt, thorough evaluation in an attempt to rapidly identify and treat the cause of the symptoms.
  3. The purpose of this case report is to alert clinicians about atypical thyrotoxicosis presentations which, if overlooked, can rapidly progress to life-threatening multi-organ failure.

To cite this abstract:

Sharma, P; AlQsous, N; Naidu, YV; Aldaoud, M; Wohlgemuth, I . THYROID STORM MIMICKING INTRA-ABDOMINAL SEPSIS IN A YOUNG FEMALE. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 718. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/thyroid-storm-mimicking-intra-abdominal-sepsis-in-a-young-female/. Accessed September 19, 2019.

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