ESPE Abstracts

Background: Thyroid storm is a rare occurrence of severe thyrotoxicosis, most commonly associated with Grave’s disease and is reported to have a high morbidity and mortality. It is particularly rare in children. Whilst there is a scoring system to diagnose thyroid storm in adults, there is not an equivalent for children. Here, we describe the case of a patient who developed thyroid storm secondary to influenza A infection.

Case Report: A 13-year-old girl had a matched unrelated donor transplant for CTPS1 deficiency immunodeficiency. Six months post-transplant, she developed heat intolerance and palpitations. On examination, she had a fine tremor but no goitre or exophthalmos.. Her temperature was above 38 degrees C for two days, she was tachycardic with HR >140, flushed and had diarrhoea. There was no CNS dysfunction. She was found to have TSH < 0.01 mu/l and free T4 of > 100 pmol/l with fT3 of 17.0 pmol/l. She was negative for TSH receptor and TPO antibodies. Thyroid ultrasound demonstrated increased vascularity and heterogenous echogenicity. Neutrophil count of 0.54 x 10^9/l secondary to bone marrow transplant. She was found to be Influenza A virus positive at the time that she was symptomatic with thyroid storm. As agranulocytosis is a possibility with carbimazole, it would be difficult to add this risk to her pre-existing post-transplant neutropenia. We therefore managed her with lugols iodine and intravenous hydrocortisone. Her thyroid function began to normalise within three days and T4 level was reduced to 29 pmol/l one week after staring treatment. She then developed hypothyroidism despite withdrawal of Lugol’s iodine and 2 months after the initial thyrotoxic phase was started on Levothyroxine. She currently takes 125 micrograms daily levothyroxine.

Discussion: This 13 year old patient developed thyrotoxicosis secondary to influenza infection. The clinical picture was of an acute thyroiditis eventually evolving into hypothyroidism. One previous case reports a young adult patient developing thyrotoxicosis secondary to H1N1 infection. However, there are no previous reported cases of thyrotoxicosis in children secondary to influenza A infection. There are no reports of stem cell transplant resulting in hyperthyroid storm. This case highlights that it is important to maintain an open mind on differential diagnoses in patients with raised temperatures; if infection does not seem to explain all of the findings, consider other causes such as thyroid disorders. Influenza A may be a rare cause of acute thyroid dysfunction in children.