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.
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 ABSTRACT Objective: 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 Methods: A 17-year-old African American female presented to the hospital with complaints of nausea, vomiting, and diarrhea associated with palpitations for 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 mg intravenous (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 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 Copyright â 2019 AACE àIU/mL (normal, 0.5 to 4.7 àIU/mL) with a free thyroxine of 4.90 ng/dL (normal, 0.8 to 2.0 ng/dL) and free triiodothyronine >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 thyrotoxicosis 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 atypical presentations For example, the most common rhythm disturbance in hyperthyroid states is sinus tachycardia, with atrial fibrillation and less common forms of supraventricular tachycardia ranging only from 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 AACE CLINICAL CASE REPORTS Vol No November/December 2019 e393 e394 Tachycardia and Thyrotoxicosis, AACE Clinical Case Rep 2019;5(No 6) Copyright © 2019 AACE 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 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 department, the patient had a fever of 100.1ºF and was tachycardic at 180 beats per minute (bpm) Physical examination was otherwise unremarkable, with no signs of goiter, cervical lymphadenopathy, exophthalmos, or pretibial myxedema 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 mg intravenous (IV) push of adenosine, 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 triiodothyronine (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,