ESPE Abstracts

Introduction: Thyroid storm is an acute, life-threatening, emergency in children with thyrotoxicosis. It is extremely rare and could be an initial presentation in previously undiagnosed children. Thyroid storm with diabetes insipidus (DI) has been reported in adults, but no cases have been reported in children. We herein report a child with thyroid storm with transient central DI.

Case Report: A 7-year-old girl, presented to the emergency department with high grade fever, headache, lethargy and an episode of generalised tonic clonic seizure (GTCS). On examination, she was pyrexic (temperature 39.2'C), tachycardic (heart rate 170/min), hypertensive (systolic blood pressure 140 mmHg) and had mottled skin. Intravenous antibiotics & antivirals were commenced suspecting meningoencephalitis. Initial investigations including full blood count, serum electrolytes, liver function test, cerebrospinal fluid analysis and CT brain were normal. C-Reactive Protein was elevated. Worsening of her clinical status resulted in admission to intensive care unit. Noticed to have goitre on subsequent detailed clinical examination which prompted measurement of thyroid function test [free thyroxine >100 (N:11.0-21.2pmol/L), free tri-iodothyronine 17.8 (N: 3.1-6.8pmol/L) and undetectable TSH <0.01mIU/L]. Subsequent focused history revealed 8-months history of weight loss despite excessive appetite, hyperactive behaviour (reduced attention span) and prominence of eyes. In view of clinical presentation and thyroid function test results, diagnosis of Thyroid Storm was made, and started immediate treatment with Carbimazole (0.75mg/kg/day), Lugol’s iodine solution (0.3 ml 8 hourly), Propranolol (250 mcg/kg 8 hourly) and intravenous Hydrocortisone (2mg/kg/dose 6 hourly). Elevated TSH-receptor antibodies 10.2 (N<1.75U/L) and anti-TPO antibodies 96 (N<34U/ml) confirmed the diagnosis of Graves’ disease. Ultrasound Thyroid showed enlarged and heterogenous thyroid gland with increased vascularity. Other investigations results (Blood and CSF cultures, Renal Doppler, Chest radiograph, Echocardiogram) were normal, not suggestive of another cause for her presentation. She subsequently developed polyuria (11ml/kg/hour), associated with normal blood glucose and high serum sodium (158mmol/L). Paired osmolality for plasma (320mOsm/kg) and urine (310mOsm/kg) indicated partial DI. She responded well to sublingual Desmopressin. Pituitary MRI was normal, including presence of posterior pituitary bright spot. DI resolved spontaneously within 3 days. With anti-thyroid treatment, she showed gradual improvement in clinical and biochemical parameters.

Conclusion: In critically ill children, apart from the usual suspects (Sepsis, Hypovolemia) potential for other offenders should not be overlooked. Detailed history and clinical examination is of paramount importance. A high index of suspicion, rapid diagnosis and prompt treatment is crucial as thyroid storm can be fatal if left untreated.