Case Presentation: A 24-year-old female with unremarkable past medical history, presented to urgent care for two days of tachycardia, chest tightness, sore throat, and fever. She was found to be in supraventricular tachycardia with a heart rate (HR) of 180 bpm. Patient received adenosine 6mg and then 12mg with improvement of HR to 140 bpm. On a physical exam she was found to have severe pharyngitis with the posterior oropharynx grossly erythematous and purulent, a non-tender goiter was present, lung sounds were clear to auscultation, and legs were without pedal edema. Patient was given 10mg dexamethasone, ampicillin/sulbactam, and toradol. Lab evaluation showed an undetectably low Thyroid stimulating hormone of < 0.007 UIU/mL and increased Free T4 of >8 ng/dL. Anti-Thyroglobulin antibody, Thyroid Peroxidase antibody, and T3 total were all within normal limits. The rapid antigen test for group A Streptococcus (GAS) by DNA probe was positive. Additionally, the patient’s Liver Function Test (LFT) showed slight elevation in AST/ALT, alk phos, and bilirubin. Brain Natriuretic Peptide (BNP) was found to be 2,026 pg/ml with an echocardiogram negative for cardiomyopathy or valvular disease. Her initial Burch-wartofsky scale showed a score of 55 and a diagnosis of thyrotoxicosis/Thyroid storm was made. Treatment was initiated with propranolol, propylthiouracil, potassium iodide, hydrocortisone, and amoxicillin/clavulanate. Patient showed clinical and biochemical response to treatment with free T4 improving to 5.6 ng/L and propylthiouracil was transitioned to methimazole. The patient was ultimately discharged with amoxicillin/clavulanate, methimazole, and propranolol for treatment of Thyrotoxicosis precipitated by Group A strep pharyngitis. Lisinopril was added for persistent and uncontrollable hypertension. At follow-up the patient was asymptomatic, and methimazole/propranolol were discontinued.
Discussion: This case demonstrates a clinical presentation of thyrotoxicosis/thyroid storm secondary to Strep throat. Thyrotoxicosis is a common endocrine condition that has multiple triggers, the most common being medication noncompliance followed by acute infection. Thyroid storm is a rare entity that represents the severe end of the spectrum of thyrotoxicosis and is characterized by compromised organ function and a high mortality rate. In contrast, GAS is the most common cause of bacterial pharyngitis in children and adults. We present a case of thyrotoxicosis precipitated by GAS and the importance of early diagnosis/intervention given the high mortality rate of thyroid storm. The patient presented with fever, tachyarrhythmia, elevated BNP, elevated LFTs, and had good response to treatment after rapid recognition and initiation of appropriate interventions.
Conclusions: It’s important that thyroid storm be recognized early in its presentation, and evaluation for precipitating factors be thorough and complete for treatment to be initiated and to prevent clinical deterioration. This is key given the high mortality rate of this rare endocrine emergency.
