Thyroid Storm Triggered by Strangulation in a Patient with Undiagnosed Graves' Disease

Acute Thyroiditis in a Patient with Neck Trauma

The management of patients with major depressive disorder who present with self-injurious behavior is best optimized through a collaborative interprofessional approach. We describe a case of a 27-year-old woman without personal or family history of thyroid pathology who presented at the emergency department due to a suicide attempt by hanging. On examination, she was tachycardic with palpitations which persisted despite administration of analgesics and anxiolytics. Left temporal area swelling, left otorrhagia, and neck contusion were noted, involving consults with the Trauma, Neurosurgery, and Otorhinolaryngology teams. She was admitted to the psychiatric ward on account of persistent suicidal ideations. As part of the workup, thyroid function tests were done to rule out hypothyroidism as a cause of depressive symptoms. Results instead showed suppressed thyroid stimulating hormone and elevated free T4. Endocrinology service was consulted, and further workup showed absence of avid uptake of both thyroid glands on thyroid scan and undetectable thyrotropin receptor antibody level, supportive of a diagnosis of trauma-induced thyroiditis. This case increases awareness that trauma-induced thyroid dysfunction should be considered in patients with symptoms including, but not limited to, tachycardia and palpitations after a traumatic neck injury such as hanging.

A case of thyroxine (T4) toxicosis complicated by thyroid storm with an unusual precipitant

Background:

Thyrotoxicosis, though commonly encountered in endocrinology practice in Nigeria, seldom presents solely as thyroxine (T4) toxicosis. Thyroid storm, a known life-threatening complication of thyrotoxicosis, can be precipitated by myriad factors. Fine need aspiration for cytology is not known, and has not been previously reported (to the best of our knowledge) to precipitate thyroid storm.

Case Presentation:

The case described is that of a 55 year old woman who presented with a neck swelling and features of hyperthyroidism, with biochemical parameters in keeping with T4 toxicosis. Investigating the patient necessitated a fine needle aspiration of the thyroid swelling. The patient thereafter developed hyper-metabolic features, and subsequently progressed to confusion and loss of consciousness few hours following the procedure. Close monitoring and medical management with anti-thyroid and other supportive therapies, resulted in an improved clinical condition.

Conclusion:

T4 toxicosis is a distinct biochemical entity of clinical significance. Physicians should bear in mind that micro-trauma from an investigation such as fine needle aspiration of the thyroid gland can tilt a thyrotoxic patient into thyroid storm, and this risk should be considered and prepared for by physicians and patients.

Strangulation-Induced Thyrotoxicosis in a Patient with Undiagnosed Underlying Graves' Disease

Thyrotoxicosis is a constellation of symptoms including palpitations, tremors, agitation, and heat intolerance, caused by excess thyroid hormone. It can be life-threatening in its most serious form. We present a rare case of thyrotoxicosis provoked by mechanical trauma to the neck via strangulation in a young female with a history of self-resolving postpartum symptoms of hyperthyroidism one year prior, but no formal diagnosis of thyroid dysfunction. Although hyperthyroidism and posttraumatic stress have many similar features, thyroid storm is a life-threatening disorder that needs immediate intervention.

Hyperthyroidism

Hyperthyroidism is a condition where the thyroid gland produces and secretes inappropriately high amounts of thyroid hormone which can lead to thyrotoxicosis. The prevalence of hyperthyroidism in the United States is approximately 1.2%. There are many different causes of hyperthyroidism, and the most common causes include Graves' disease (GD), toxic multinodular goiter and toxic adenoma. The diagnosis can be made based on clinical findings and confirmed with biochemical tests and imaging techniques including ultrasound and radioactive iodine uptake scans. This condition impacts many different systems of the body including the integument, musculoskeletal, immune, ophthalmic, reproductive, gastrointestinal and cardiovascular systems. It is important to recognize common cardiovascular manifestations such as hypertension and tachycardia and to treat these patients with beta blockers. Early treatment of cardiovascular manifestations along with treatment of the hyperthyroidism can prevent significant cardiovascular events. Management options for hyperthyroidism include anti-thyroid medications, radioactive iodine, and surgery. Anti-thyroid medications are often used temporarily to treat thyrotoxicosis in preparation for more definitive treatment with radioactive iodine or surgery, but in select cases, patients can remain on antithyroid medications long-term. Radioactive iodine is a successful treatment for hyperthyroidism but should not be used in GD with ophthalmic manifestations. Recent studies have shown an increased concern for the development of secondary cancers as a result of radioactive iodine treatment. In the small percentage of patients who are not successfully treated with radioactive iodine, they can undergo re-treatment or surgery. Surgery includes a total thyroidectomy for GD and toxic multinodular goiters and a thyroid lobectomy for toxic adenomas. Surgery should be considered for those who have a concurrent cancer, in pregnancy, for compressive symptoms and in GD with ophthalmic manifestations. Surgery is cost effective with a high-volume surgeon. Preoperatively, patients should be on anti-thyroid medications to establish a euthyroid state and on beta blockers for any cardiovascular manifestations. Thyroid storm is a rare but life-threatening condition that can occur with thyrotoxicosis that must be treated with a multidisciplinary approach and ultimately, definitive treatment of the hyperthyroidism.