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Rare Presentation of Thyroid Storm with Diffuse Alveolar Hemorrhage
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A6593 - Rare Presentation of Thyroid Storm with Diffuse Alveolar Hemorrhage
Author Block: G. Malhotra1, A. Khurana2, L. Srinivasan3; 1Chicago Medical School/RFUMS, North Chicago, IL, United States, 2Pulmonary, Vista Hospital, Waukegan, IL, United States, 3Vista Hospital, Waukegan, IL, United States.
Introduction:
Diffuse alveolar hemorrhage (DAH) can be a life-threatening condition and may rarely present as a complication of methimazole therapy.
Case Presentation:
A 44-year-old female with a history of hyperthyroidism with poor compliance with methimazole therapy presented with complaints of vomiting and massive hemoptysis. She did not have any preceding illness, respiratory infections, dyspnea, fever or trauma. She woke up with vomiting and then started having hemoptysis on the day of admission requiring intubation for acute respiratory failure. She was not taking any anticoagulants or antiplatelet medications and had poor compliance with methimazole at home. She was afebrile however in respiratory distress and tachycardic. Chest Xray revealed bilateral infiltrates and diffuse ground-glass opacities were seen on CT chest. Pulmonary embolism was ruled out. An abnormally large multinodular thyroid gland was also noticed.
An emergent bronchoscopy was performed which revealed a significant amount of diffuse bleeding without clearing on sequential aliquots. Analysis of bronchioalveolar lavage showed hemosiderin-laden macrophages. Blood work was remarkable for significantly elevated free T3 and T4 levels with undetectable TSH. ESR was normal however CRP was elevated at 103. Serological work up for vasculitis was essentially unremarkable. Urine drug screen was positive for cannabinoids. Further workup including bronchial wash cultures, blood cultures, fungal serologies and HIV testing did not reveal any infectious etiology.
She was started on pulse dose of methylprednisolone for management of DAH while waiting for the serology and also on propranolol as well as methimazole for thyroid storm. She was initially extubated with improvement in respiratory status however required reintubation for respiratory failure with worsening bilateral infiltrates on chest Xray. Methimazole was then switched to propylthiouracil and steroids tapered down. Repeat bronchoscopy did not reveal any more signs of DAH. She was eventually successfully extubated and levels of free T3 improved significantly.
Discussion:
Methimazole is a rare cause of DAH and is a diagnosis of exclusion. In the previously reported cases, antineutrophil cytoplasmic antibody (ANCA) positivity has been documented in relation to the use of methimazole. There has been one reported case of methimazole associated DAH without serology positive for ANCA.
Conclusion:
Methimazole-induced DAH requires the withdrawal of offending drug and treatment with steroids.
Author Block: G. Malhotra1, A. Khurana2, L. Srinivasan3; 1Chicago Medical School/RFUMS, North Chicago, IL, United States, 2Pulmonary, Vista Hospital, Waukegan, IL, United States, 3Vista Hospital, Waukegan, IL, United States.
Introduction:
Diffuse alveolar hemorrhage (DAH) can be a life-threatening condition and may rarely present as a complication of methimazole therapy.
Case Presentation:
A 44-year-old female with a history of hyperthyroidism with poor compliance with methimazole therapy presented with complaints of vomiting and massive hemoptysis. She did not have any preceding illness, respiratory infections, dyspnea, fever or trauma. She woke up with vomiting and then started having hemoptysis on the day of admission requiring intubation for acute respiratory failure. She was not taking any anticoagulants or antiplatelet medications and had poor compliance with methimazole at home. She was afebrile however in respiratory distress and tachycardic. Chest Xray revealed bilateral infiltrates and diffuse ground-glass opacities were seen on CT chest. Pulmonary embolism was ruled out. An abnormally large multinodular thyroid gland was also noticed.
An emergent bronchoscopy was performed which revealed a significant amount of diffuse bleeding without clearing on sequential aliquots. Analysis of bronchioalveolar lavage showed hemosiderin-laden macrophages. Blood work was remarkable for significantly elevated free T3 and T4 levels with undetectable TSH. ESR was normal however CRP was elevated at 103. Serological work up for vasculitis was essentially unremarkable. Urine drug screen was positive for cannabinoids. Further workup including bronchial wash cultures, blood cultures, fungal serologies and HIV testing did not reveal any infectious etiology.
She was started on pulse dose of methylprednisolone for management of DAH while waiting for the serology and also on propranolol as well as methimazole for thyroid storm. She was initially extubated with improvement in respiratory status however required reintubation for respiratory failure with worsening bilateral infiltrates on chest Xray. Methimazole was then switched to propylthiouracil and steroids tapered down. Repeat bronchoscopy did not reveal any more signs of DAH. She was eventually successfully extubated and levels of free T3 improved significantly.
Discussion:
Methimazole is a rare cause of DAH and is a diagnosis of exclusion. In the previously reported cases, antineutrophil cytoplasmic antibody (ANCA) positivity has been documented in relation to the use of methimazole. There has been one reported case of methimazole associated DAH without serology positive for ANCA.
Conclusion:
Methimazole-induced DAH requires the withdrawal of offending drug and treatment with steroids.
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