Mrs. Black is a 31 year old female who is 2 weeks postpartum.  This morning her husband found her difficult to rouse and confused, and called 911.  The husband indicates she has been quite anxious since the birth of their first child. He reports she has had nausea and vomiting for two days, as well as watery diarrhea and generalized abdominal pain.  She hasn’t been able to breastfeed baby because she’s been too anxious. Husband denies any sick contacts or recent travel.

Upon further questioning, the husband reports Mrs. Black has a history of Hyperlipidemia, Graves Disease, and asthma and takes simvastatin and propylthiouracil daily, plus her rescue inhaler when she needs it. Upon assessment, Mrs. Black is somnolent and only minimally responsive to painful stimuli. She is unable to answer orientation questions and just keeps repeating her husband’s name.  The nurse notes redness to her eyes and swelling around her eyelids. Heart rate is rapid and irregular. Lungs have diffuse crackles bilaterally. Vital signs are as follows:

HR 145 bpm

BP 120/76 mmHg

RR 32 bpm

Temp 101°F 

SpO2 89% on 4L nasal cannula

 

Mrs. Black becomes more obtunded and her heart rate goes up to 155. The provider orders a 12-lead EKG and proceeds to prepare for intubation for airway protection. The Respiratory Therapist comes to bedside and notes the patient has a swollen thyroid gland. For this reason, the Anesthesia team is called to the bedside to assist in a successful intubation. The provider orders a full lab panel, including CBC, CMP, LFTs, and a Thyroid Panel, plus an Arterial Blood Gas, and consults the ICU team to admit Mrs. Black.

This is the 12-lead EKG:

By James Heilman, MD – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19126125

Lab results return on Mrs. Black as she is transferred to the ICU:

Na 144 pH 7.33 TSH 0.1

K 5.0 pCO2 48 WBC 14K

Mg 1.0 HCO3– 24 Hgb 12.5

BUN 11 pO2 190 Hct 38%

Cr 0.7 Lactate 3.2 Plt 450K

The provider orders a beta blocker and IV fluids for Mrs. Black, as well as an increased dose of propylthiouracil (PTU).  She is stable for now, but it may take a few days for her to overcome this thyroid storm/crisis. Her husband asks the nurse what caused this.