Neck Mass and Fever

37yr old female presents with 2 days of a swollen neck mass on the right side. Pt states she started having myalgias and neck stiffness over the weekend and fevers as high as 102. She was seen at outside hospital Sunday and was told everything was fine. Then Monday morning pt began having neck stiffness, dysphagia for liquids more than solids and odynophagia. Pt continues to have fevers as high as 102 which respond to tylenol and ibuprofen. Pt saw family friend who was a doctor 2 days ago and given cephelexin. Pt sent from PCP office today for further evaluation and requests neck CT. Pt is 8 months post partum and is breast feeding.

Vital Signs:
BP 123/66, pulse 113, temperature 98.7 degrees F, resp. rate 16,

Neck: R sided neck tenderness and fullness.  No stridor. No difficulty managing secretions.

CV:RRR, NO MRG
Lungs: Clear to auscultation bilaterally. No wheezing.

Workup:

CT neck: negative for abscess or lymphadenitis
TSH<0.008
T3 9.6
T4 3.48

This patient was diagnosed with thyroidits and subsequent hyperthyroidism (that we felt was caused by a viral infection) and discharged with endocrine follow up and Propanolol

Thyroid Storm was discussed(which this patient did not have…although she was pretty hyperthyroid):

Teaching points:

1)These people can be really sick
2) Symptoms are those of enhanced sympathetic activity: fever, tachycardia, AMS, GI sx
3) Lab findings: leukocytosis, hyperglycemia, sometimes elevated transaminases (according to Tintanelli)
4) Treatment of thyroid storm has to be in a certain order:
      a) use beta blockers first: Propanolol or Esmolol
      b) Propylthiouracil decreases new synthesis and conversion of T4 to T3
      c) Methimazole
      e) usually not in ED : Iodine..of note: do not give until sympathetic PW is blocked
      f) Steroids if evidence of adrenal insufficiency…which can be seen in these patients
      g) antipyretics

Wanna know more about thyroid storm?  CHECK OUT EMRAP June 2010…here are the notes on hyperthyroidism

Hyperthyroidism
Jonathon Lopressti, MD Stuart Swadron, MD

I. Progression of thyroid storm: a clinical diagnosis
1. Underlying hyperthyroidism
2. Fever – normal vasodilatation with heat dissipation is lost
3. Altered mental status – the key to diagnosis
    Wide range: mild impairment, psychosis, frank coma
    A thyrotoxic patient with normal mentation is much less worrisome
4. Precipitating event – increases catecholamines to preexisting hypersensitive beta adrenergic receptors
    Infection – may not have leukocytosis
    Trauma – may require beta-­‐blockers; trepidation with trauma patients;  Surgery – may unmask hyperthyroidism
    Excessive diuresis – these patients have a wide-­‐open circulation
II. Differences in patient population:
• Elderly: difficult to diagnose
     They do not show the overt physical signs of hyperthyroidism
     Cell surface beta receptors are internalized as we age
     Clues to diagnosis -­‐ supraventricular arrhythmias, heart failure, inappropriately youthful skin
• The young: difficult to treat
     They do not tolerate hyperthyroidism as well as the elderly
     Increased beta receptors result in exaggerated adrenergic response;  More likely to die from circulatory collapse
III. Laboratory findings:
• Thyroid function tests
• CBC
     Anemia– Hgb~12
     Thrombocytopenia
• Electrolytes
    Serum Cr low– cannot convert creatine to creatinine;  Hypercalcemia
IV. Treatment:
1. Cover for infection
      Like myxedema coma, patients with hyperthyroidism have difficulty mounting a white count
     Therefore, treat any WBC counts w/left shift as infection, pan-­‐culture & start broad spectrum antibiotics
2. Symptomatic relief: beta blockade
     How do you approach beta blockade in a patient with a mixture of tachycardia and volume depletion that may
be contributing to hypotension and hemodynamic instability?
    The majority of CHF in thyroid storm is high output & will respond to beta blockers
    Diuretics are contraindicated– they are hypovolemic
    Propanolol 1 mg IV (test dose)
    Follow the HR & BP over 5 minutes (half-­‐life = 5 minutes); if BP is maintained, safe to proceed;  Transition to oral dose (120mg-­‐240mg PO daily)
    If BP drops, give IVF judiciously and wait
    Propanolol drip – if unable to tolerate PO
    Max 3-­‐5 mg/hr
    Goal HR = 90-­100 bpm (any lower will lead to cardiovascular collapse)
3. Lower thyroid hormone levels
    Propylthiouracil
    100-­‐150 mg PO q8 hours (maximal blocking effect occurs at 50mg)
    Decreases thyroid hormone synthesis and inhibits conversion of T4–>T3 –> May use methimazole in lieu of propylthiouracil
    Potassium iodide
    10 gtt of 1g/ml PO
    Give 1 hour after PTU or methimazole
     Further inhibits release of thyroid hormone
     Glucocorticoid
    Decadron 4mg IV q6h
4. Temperature regulation
    Aggressively cooling these patients is contraindicated
    Can lead to vasoconstriction & shivering–>paradoxical elevations in temperature –> Use agents that affect heat regulation via the hypothalamus
    Thorazine 25 mg IV ; Demerol 25 mg IV

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