Case #016

Free T4 and T3 this high do not by themselves make an emergency, since those levels overlap heavily with the thyrotoxicosis that walks into an outpatient clinic. What marks this as storm is the organ failure stacked on top: a temperature of 39.8 °C that the paracetamol given in triage did not touch, agitation with disorientation, atrial fibrillation at 168 with a wide pulse pressure, and bibasal crackles announcing heart failure. Underneath sits months of weight loss despite a large appetite, constant sweating and broken sleep. The diffuse goitre with a bruit, lid lag and a positive TSH receptor antibody name the cause as Graves' disease, untreated since she stopped her thionamide eight months ago. The dental abscess is the precipitant: infection, surgery, trauma, childbirth and iodinated contrast are the classic triggers that tip compensated thyrotoxicosis over. Hypercalcemia reflects thyroid hormone-driven bone resorption, and the raised transaminases and lactate reflect hypermetabolic stress, not separate pathology. The main mimics (sepsis, neuroleptic malignant syndrome, serotonin syndrome and sympathomimetic toxicity) are argued against by the absence of rigidity, clonus and relevant drug exposure, and by fever that persists despite appropriate antibiotics. Treatment is multi-layered and started on clinical suspicion alone: a thionamide (propylthiouracil is preferred in crisis because it also blocks peripheral T4-to-T3 conversion), a beta blocker such as propranolol for adrenergic control, and corticosteroids, which further inhibit conversion and cover the relative adrenal insufficiency of crisis. Iodine, if used, must be given at least an hour after the thionamide, or it will fuel further hormone synthesis. Active cooling and continued treatment of the precipitant run alongside all of it.