key: cord-0713764-gnmkp24l
authors: Rao, Angela N.; Al-Ward, Ruaa Y.; Gaba, Ruchi
title: Thyroid Storm in a Patient With COVID-19
date: 2021-07-03
journal: AACE Clin Case Rep
DOI: 10.1016/j.aace.2021.06.011
sha: 441d6a93fb574ab1f055dd7da9a1f912194ad44f
doc_id: 713764
cord_uid: gnmkp24l

OBJECTIVE: A thyroid storm is a severe exacerbation of thyrotoxicosis that can cause significant morbidity and mortality. The emergence of the novel coronavirus (SARS-CoV-2) that originated in Wuhan, China, has become a worldwide pandemic. We present the first documented case of thyroid storm (as defined by the Burch-Wartofsky criteria) in a patient with COVID-19. METHODS: Laboratory and diagnostic studies, including thyroid function tests, thyroid antibody testing, SARS-CoV-2 nasopharyngeal polymerase chain reaction testing, and thyroid ultrasound were performed. RESULTS: A 25-year-old woman presented to the hospital with dry cough, dyspnea, palpitations, weight loss, diarrhea, and anxiety. Physical examination revealed exophthalmos with proptosis and chemosis, tachycardia, diffusely enlarged goiter with bruit, and fine tremor. Laboratory results demonstrated a thyroid-stimulating hormone level of <0.01 mIU/L (normal range [NR], 0.44-5.3 mIU/L), free thyroxine level of 5.34 ng/dL (NR, 0.64-1.42 ng/dL), total triiodothyronine level of 654 ng/dL (NR, 87-178 ng/dL), and thyroid-stimulating immunoglobulin level of 7.18 IU/L (NR, 0.00-0.55 IU/L). Thyroid ultrasound revealed heterogeneous echotexture with increased vascularity. Nasopharyngeal COVID-19 testing was positive. She was treated promptly with propranolol, propylthiouracil, and hydrocortisone with improvement in symptoms, and later switched to methimazole. Her COVID-19 course was uncomplicated, and she left the hospital with minimal respiratory symptoms. CONCLUSION: Thyroid storms are one of the more prevalent endocrine emergencies and are often precipitated by acute events including infections. Patients with thyroid storms may have concomitant SARS-CoV-2 infection that could influence the clinical course and severity of the disease. In patients with symptoms of thyrotoxicosis and respiratory symptoms, clinicians should consider performing a COVID-19 test.

Thyroid storm is defined as a life-threatening exacerbation of thyrotoxicosis, and is characterized by tachycardia, hyperthermia, agitation, altered mental status, and other organ system dysfunction. It is a clinical emergency that without early diagnosis and treatment can be fatal, with recent sources reporting a mortality rate anywhere from 3.3-25% (1) (2) (3) Since January 2020, coronavirus disease caused by SARS-CoV-2 infection has been known to precipitate endocrinologic emergencies such as diabetic ketoacidosis, and can result in thyroid-related complications including subacute thyroiditis. (4) (5) We are reporting what we believe to be the first case of thyroid storm in a patient with COVID-19.

A 25-year-old, Hispanic woman with medical history of obesity (BMI 32.0), fatty liver disease, gastritis, and obstructive sleep apnea, presented to the emergency room in Houston, TX in August 2020 with one week of intermittent shortness of breath and J o u r n a l P r e -p r o o f palpitations. Her symptoms first started over one year prior to presentation, and included palpitations, weight loss, shaking, throat swelling, and dizziness, for which she did not initially seek medical care. She was evaluated at a community health clinic in February 2020 and was told she had a thyroid problem, but was not started on any medications and did not follow up. During the week leading to this hospital admission, she noticed a significant worsening of her baseline symptoms, including palpitations, diarrhea, anxiety, and heat intolerance, without any known precipitating factor. Review of systems was negative for fever, however she did have dry cough and intermittent shortness of breath during this time. While at work, she noticed her resting heart rate had increased to the 160s, prompting her to come to the hospital.

On physical examination, she was anxious, agitated, and restless with increased fidgeting. Vitals on admission were as follows: Temperature: 98.8 F, heart rate 142 beats per minute, blood pressure 156/92 mmHg, oxygen saturation 100% on room air. She had diffusely enlarged goiter with bruit. Eyes showed proptosis, chemosis, and lid lag. were within normal ranges. HIV and pregnancy testing were negative. She was tested for SARS-CoV-2 via RT-PCR testing, and it resulted as positive for the presence of detectable RNA. Initial chest radiograph was normal, and admission ECG showed sinus tachycardia with a rate of 164 bpm. Ultrasound of thyroid revealed heterogeneous echotexture with increased vascularity, highly suggestive of thyroiditis.

Burch-Wartofsky score was calculated as 55 points: for agitation in the form of restlessness, diarrhea, heart rate >140 beats per minute, and precipitating event of COVID-19 infection. She was started on propranolol 80mg every 4 hours titrated to heart rate <90 bpm, and propylthiouracil 200mg every 8 hours. Hydrocortisone 50mg every 8 hours was also added to decrease peripheral conversion of T4 to T3.

There was significant improvement in tachycardia and symptoms after initiation of medications ( Figure 1 ). Biochemical profile seemed to improve slowly but steadily with reduction of total T3 and free T4 during hospitalization (Figure 2a and 2b) . Regarding COVID-19, her course was unremarkable. Throughout her hospitalization, she had no decrease in oxygen saturation or radiographic evidence of disease. Her shortness of breath which was present on admission improved with treatment of thyroid storm, but she continued to have a mild, dry cough during hospitalization and on discharge. White and there are no universally accepted peer-reviewed criteria for diagnosis. (6) The point scale by Burch-Wartofsky is most widely used in United States, but is empirically derived and may over-diagnose some cases of thyroid storm. (7) In 2012, new diagnostic criteria were proposed by the Japan Thyroid Association, which included the prerequisite of lab findings of thyrotoxicosis along with a combination of CNS and other organ system dysfunction. (8) In the case of our patient, she met the criteria of thyroid storm as defined by both the Burch-Wartofsky Point Scale as well as the "TS1"criteria (definite thyroid storm) proposed by the Japan Thyroid Association. However, she notably had no congestive heart failure, pulmonary edema, elevated bilirubin, nor central nervous system manifestation aside from restlessness. Although she met both technical definitions of thyroid storm, she likely did not represent a life-threatening case at time of admission.

The precise mechanism of uncomplicated hyperthyroidism or thyrotoxicosis evolving into thyroid storm is not well known, however there is almost always a superimposed insult that precipitates it. Increased sensitivity to catecholamines is thought to play a role. (2) Infection, thyroid and non-thyroid surgery, parturition, major trauma, and use of certain drugs are all known causes. Though autoimmune thyroid disease in itself is not linked to increased risk of COVID-19, uncontrolled thyrotoxicosis with SARS-CoV-2 infection could precipitate a more severe course of thyroid disease. In our patient, it is J o u r n a l P r e -p r o o f possible that infection with SARS-CoV-2 pushed her from stable thyrotoxicosis to thyroid storm. A July 2020 retrospective study in the European Journal of Endocrinology suggested that COVID-19 may be associated with a high risk of thyrotoxicosis, due to the relationship with immune system activation induced by SARS-CoV-2 infection. (9) It was recently reported that patients with COVID-19 show high levels of pro-inflammatory cytokines and chemokines. (10) (11) Pro-inflammatory cytokines such as IL-6 and IL-8 have been shown to be elevated in untreated thyrotoxicosis, and fall as thyroid levels normalize with medical treatment. (12) In our patient, we used the Burch-Wartofsky scoring system along with clinical and biochemical presentation to recognize thyroid storm. (13) The presence of a precipitating event (SARS-CoV-2 infection, albeit a mild case), bumped her score from borderline thyroid storm to overt thyroid storm. Although she was previously told she had a thyroid problem, she had not been started on any antithyroid therapy, so she had no alternative precipitating factor such as medication noncompliance. Regarding the positive COVID-19 test, we believe her test can be interpreted as a true positive.

According to the BMJ, the probability of actually having COVID-19 with positive RT-PCR test is 98%. (14) Additionally, she had exposure risk as she worked in a healthcare clinic, and was symptomatic with dry cough and shortness of breath.

Early recognition of thyroid storm, in part due to prompt COVID-19 testing, helped to initiate therapy that is essential in reducing mortality. Treatment in our patient was guided towards inhibiting thyroid hormone synthesis, counteracting the peripheral effects of thyroid hormones, and reducing systemic effects including tachycardia. As J o u r n a l P r e -p r o o f infections due to SARS-CoV-2 continue to be prevalent, it is essential to test all symptomatic patients for COVID-19, as it may guide clinical decision making in situations such as thyroid storm. Although there have been case reports of COVID-19-related subacute thyroiditis, this appears to be the first documented case of thyroid storm as defined by Burch-Wartofsky criteria in a patient positive for COVID-19. (5) As we continue to learn more about the novel coronavirus, a more definitive link regarding its role in thyrotoxicosis may emerge.

J o u r n a l P r e -p r o o f

National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States

Thyroid storm: an updated review

Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis

COVID-19 infection may cause ketosis and ketoacidosis

Subacute Thyroiditis After Sars-COV-2 Infection

American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

Thyroid Storm: A Japanese Perspective

Thyrotoxicosis in patients with COVID-19: the THYRCOV study

The cytokine storm in COVID-19: An overview of the involvement of the chemokine/chemokine-receptor system

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Serum cytokines in thyrotoxicosis

Life-threatening thyrotoxicosis. Thyroid storm

Interpreting a covid-19 test result