Presentation
Emergency admission with pleuritic chest pain, shortness of breath, cough and leg swelling. Generally unwell over two weeks, with significant weight loss over a few months. No known medical history. Non-smoker. Vacation within the last month with three hour flight. No medications. New fast AF (215 bpm).
Patient Data
Allowing for AP projection, marked cardiomegaly. Prominance of central pulmonary vessels. Small bi-basal pleural effusions.
Case Discussion
This patient presented with chest pain and breathlessness on a background of weight loss and lethargy. Further history revealed a sub-acute history of heat intolerance and fine tremor. There was a family history of over-active thyroid.
The main finding in this patient's blood tests was abnormal thyroid function: free T4 (45), elevated free T3 and thyroid receptor antibodies and fully suppressed TSH.
This biochemical and clinical scenario was consistent with thyroid storm.
There were a number of management steps this patient required in the emergency setting:
control of heart rate: the patient was in uncontrolled AF and was loaded with digoxin and given thiazide diuretics and propranolol
echocardiogram: severe left ventricular dysfunction, moderate mitral regurgitation, ejection fraction 10%
treatment of hyperthyroid state: commenced on propylthiouricil and steroids
When the heart rate was better controlled, a repeat echo confirmed the above findings and the patient underwent DC cardioversion to good effect.
Case contributed by Dr Gilly Fleming
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