Case Discussion – Metabolic Endocrinology I – 4th Semester

Thyroid Stor m in 16 Y.O

Patient With Intracranial
Ble e ding
Hambiah Hari Oki
2022

Moderator:
d r. A n i k W i d i j a n t i S p . P K ( K )
Base Data
16 y.o male patient admitted to RSSA on January 29th 2022
Chief Complaint : Loss of consciousness post traffic accident
History of Present Illness
• Patient admitted to RSSA ER due to motorcycle traffic accident with
loss of consciousness and seizure
• Seizure happened repeatedly, convulsive, and regain consciousness
between episode, he vomited 3 times, projectile
• Operated immediately in order to evacuate blood clot inside his skull

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Base Data
• Patient had history of weight loss, intolerance to heat, palpitation and
lump on his neck since 3 months ago
• He also get tired more easily, experiencing diarrhea without any clear
cause and never seek medical attention for his symptoms

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Base Data
Base Data
History of Past illness
Medical History

• History of hypertension (-)

• History of trauma, surgery in head and neck (-)

Family History

• Family with same complaint (-)

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Base Data
Base Data
History of Past illness
Social History

• Smoking (-), alcohol (-), drug abuse (-)

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 Physical Examination
General status Severely ill, GCS : hard to be evaluated, on sedation
Weight: 57 kg, Height: 165 cm, BMI: 20.9 kg/m2 (normoweight)
Vital sign BP: 136/53 mmHg, HR: 135 tpm, RR: 24 tpm, T: 38.5°C, SpO2: 97 %
on ventilator
Head & Neck Light reflex +/+, anemic conjunctiva -/-, icteric sclera -/-, mass +
(hard without any clear boundaries), NGT (+) clear residue
Thorax P : symmetrical, VBS +/+, Rh + /+ Baso-lateral, Wh -/-
C : Cardiomegaly -, Regular S1/S2, murmur -, gallop -
Abdomen Concave , bowel sound (n), organomegaly (-)
Extremities Warm +/+, oedema -/-, CRT < 2s
Skin Within normal limit
Genitalia Folley catheter (+)
Other Ventricular drain (+), active bleeding 6
Laboratory Result

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Hematology 29/01 30/01 01/02 Reference
Hb 15.4 Operated 12.4 10.8 11.4-15.1 g/dL
RBC 5.7 4.61 4.04 4-5 x 106/µL
Ht 46.7 38.2 34.4 38 – 42 %
MCV 81.9 82.9 85.1 80 – 93 fL
MCH 27 26.9 26.7 27 – 31 Pg
MCHC 33 32.5 31.4 32 – 36 g/dL
RDW 14.6 15.3 15.3 11.5 – 14.5%
WBC 14.92 10.35 7.15 4.7 - 11.3 x103 /µL
Diff count 0-4/0-1/51-67/25-
1/-/78/14/7 -/-/72/15/13 -/-/75/13/12
33/2-5
ALC 2088 1552 929 1.5-4 x103 /µL
PLT 204 140 131 142 – 424 x 1038 /µL
 Chemistry 29/01 30/01 03/02 Reference
Ureum 19.9 12.9 - 16.6 -48.5 mg/dL
Creatinine 0.46 0.39 - <1.2 mg/dL
eGFR (Schwartz) 148 175 - >90mL/min/ 1.7m2
Albumin 4.32 Operated 3.28 2.43 3.5-5.5 g/dl
SGOT/ AST 36 25 - 0-32 U/L
SGPT/ ALT 29 21 - 0-33 U/L
CRP 0.06 - 8.75 <0.3 mg/dL
RBG 135 - - <200 mg/dL
29/01 03/02 Reference
Procalcitonin 0.09 0.22 < 0.5 ng/mL
29/01 Reference
RDT SARS-CoV-2 Ag Negative Negative 9
 Serum 29/01 30/01 01/02 Reference
Natrium 138 139 145 136 – 145 mmol/L
Kalium 3.53 3.9 4.35 3.5 – 5 mmol/L
Chloride 110 118 122 98 – 106 mmol/L
Immuno-serology 31/01 06/02 Reference
TSH 0.01 0.01 0.7 – 5.97 µU/mL
FT4 6.03 5.46 0.96 – 1.77 ng/mL
T3 2.4 1.8 0.91 – 2.18 ng/mL
Hemostatic 29/01 30/01 Reference
PPT 12.2 11.9 9.4 – 11.3 s
Control 11.4 10.9
INR 1.18 1.15 <1.5
APTT 29.3 26.2 24.6 – 30.6 s
Control 25.3 25.1 10
pH
BGA 29/01
7.32
04/02
7.42
Reference
7.35 – 7.45
Other Workups
Head CT Scan (29/01)
pCO2 33.2 35.6 35 - 45
• EDH frontal basal-temporal, active
pO2 91.7 114.4 80-100 bleeding
HCO3 17.3 23.3 21-28 • SDH frontal temporal
BE -8.9 -1.3 (-3)-(+3) • Cerebral oedema
SatO2 96.5 98.6 >95 % Chest X-ray (29/01)
• Within normal limit
0.5 -1.6
Lactic acid 1.1 1.4 • Fracture (-)
mmol/L
Hb 13.7 10 Chest X-ray (01/02)
Intubated
• Pneumonia
Suhu 37 37
Metabolic Acidosis Normal 11
Therapy
Therapy
• IVFD NaCl 0.9% • PO Lugol 5 x 1 gtt
• IV Metamizole 3 x 1 gr • PO Propanolol 6 x 60 mg
• IV Metoclopramide 2 x 10 mg • IV Hydrocortisone 300mg; 100 mg
• IV Mannitol 4 x 100 ml Qd8H
• IV Phenytoin 3 x 100 mg
• IV Vitamin K 3 x 1 amp
• IV Tranexamic acid 3 x 500 mg
• PO PTU 600 mg; 250 mg Qd6H

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Data Interpretation
Findings and workups
NN anemia with normal RDW, thrombocytopenia, metabolic acidosis,
leukocytosis with neutrophilia at admission → lymphopenia (ALC
<1500), hypoalbuminemia, ↑CRP, normal PCT, negative SARS-CoV-2
antigen, ↓TSH, ↑FT4, ↑T3
Post operative due to intracranial bleeding post traffic accident with
seizure, history of weight loss, intolerance to heat, palpitation, lump
on neck since 3 months ago, get tired more easily, diarrhea without
any clear cause and never seek medical attention
Tachycardia, fever, mass on neck (hard, no clear boundaries), baso-
lateral rhonchi, ventricular drain with active bleeding
Head CT Scan: intracranial bleeding, CXR: (29/01) normal → (01/02)
pneumonia 13
Data Interpretation
Diagnosis
16 y.o male patient with diagnosis of/
1. Intracranial bleeding
2. Hyperthyroid d.t suspected grave disease dd/ adenocarcinoma on
thyroid storm episode
3. Hypoalbuminemia d.t hypercatabolic state, blood loss, suspected
liver insufficiency
4. Hospital acquired pneumonia (HAP) d.t bacterial dd/ viral (SARS-
CoV-2)
5. Anemia d.t blood loss dd/ concomitant with anemia of
inflammation
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Data Interpretation
Suggestion
Thyroid USG, anti TSH receptor-antibody, FNAB (if needed), ECG,
total protein, globulin, bilirubin T/D/I, ALP, gamma GT, UL,
sputum gram stain, culture and antibiotic sensitivity test, RT PCR
SARS-CoV-2, peripheral blood smear, reticulocyte, SI, TIBC

Monitoring
Vital signs, FT4, T3, TSH, albumin, CBC, CRP, PCT

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 Discussion

Establishment of
Diagnosis
Hyperthyroidism
in this Patient

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Establishment of Diagnosis

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 Intracranial Bleeding
• Encompasses four broad type: epidural, subdural, sub-
arachnoid, intraparenchymal → results from different
etiologies with varies clinical findings, prognosis and
outcomes
• Neurological deficits and seizures are two main
complications of intracranial bleeding
• Trauma is one of factor that can precipitating thyroid storm
and few of case reports has been published
• Pre-existing and untreated abnormality of the thyroid
gland might be responsible
Tenny S, Thorell W. Intracranial Hemorrhage. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Feb 16] 18
Karaoren GY, Sahin OT, Erbesler ZA, Bakan N. Thyroid Storm Due To Head Injury. Ulus Travma Acil Cerrahi Derg. 2014;20(4):305–7.
 Anemia
• Reduction of hemoglobin content of blood → decrease in the
oxygen carrying capacity
• Can be caused by blood loss, hemolysis,
ineffective/insufficient erythropoiesis → reticulocyte count
aid in distinguished the cause
• Low serum iron (SI) and TIBC can be a finding in anemia of
chronic disease → due to inflammation process
• Blood smear may provide information on underlying cause of
inflammation → chronic hemorrhage, infection, nutritional
deficiency
Keohane EM, Smith LJ, Walenga JM.Rodak’s Hematology : Clinical Principles and Application. 5th ed. Elsevier. 2016 19
Madu AJ, Ughasoro MD. Anaemia of Chronic Disease: An In-Depth Review. Med Princ Pract. 2017;26(1):1-9.
 Hypoalbuminemia
• Hypoalbuminemia may be a result of decreased production,
increased loss, extravascular extravasation, or increased catabolism
• These mechanisms might present simultaneously
• Pro-inflammatory mediators such as IL-6, CRP inhibited albumin
production that might also be the cause of increased vascular
permeability
• Inflammatory state might cause decreased level of albumin of
increased level of globulin → change in A/G ratio
• Acute, chronic inflammation, liver, kidney disease give different
protein electrophoresis pattern
20
Gounden V, Vashisht R, Jialal I. Hypoalbuminemia. [Updated 2021 Sep 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022
CASE
Findings and workups
Hypoalbuminemia, ↑CRP, NN anemia with normal RDW, leukocytosis with
neutrophilia, metabolic acidosis
Post operative d.t intracranial bleeding, ventricular drain with active bleeding,
clinical signs of thyroid disease 3 months before admission
Head CT scan: intracranial bleeding
Intracranial bleeding
Anemia d.t blood loss dd/ concomitant with anemia of inflammation
Hypoalbuminemia d.t hypercatabolic state, blood loss, suspected liver insufficiency
Suggestion
Peripheral blood smear, SI, TIBC, reticulocyte, total protein, globulin, bilirubin T/D/I,
ALP, gamma GT, UL
Monitoring
Vital signs, albumin, CBC, CRP, SGOT, SGPT, PT, INR, aPTT, ureum, creatinine 21
 Pneumonia
• Infection of pulmonary parenchyma → HAP, CAP, VAP,
HCAP
• Microorganisms gain access to lower respiratory tract,
proliferating and host inflammatory response is activated
→ clinical syndrome of pneumonia (fever, rhonchi,
asphyxiate)
• Etiology of pneumonia usually cannot be determined solely
on clinical presentation → empiric therapy
• Identification of pathogen used to narrowing empiric
therapy and unsuspected or resistant pathogen
22
Harrison, T. Harrison’s Principles of Internal Medicine. (Mc.Graw Hill Edu., 2015).
 Hospital Acquired Pneumonia
• Also called nosocomial pneumonia, defined as pneumonia
that occurs 48 hours of more after hospital admission
• VAP represents a significant sub-set of HAP → after 48 –
72 h of mechanical ventilation
• Gram-negative bacilli such as P. aeruginosa. E. coli, and
gram-positive cocci such as MRSA are common pathogens in
HAP/VAP
• Patient with HAP usually has higher CRP (15 mg/dL) and
WBC count (14.7 x 103 /µL) with higher neutrophil count

Shebl E, Gulick PG. Nosocomial Pneumonia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Feb 21].
Russell CD, Koch O, Laurenson IF, O’Shea DT, Sutherland R, Mackintosh CL. Diagnosis and features of hospital-acquired pneumonia: a retrospective cohort study. J Hosp Infect. 2016 23
Mar;92(3):273–9.
 COVID-19
• Infection by SARS-CoV-2 that primarily affects the respiratory
system with heterogenous symptoms (asymptomatic – severe)
• Low lymphocyte count, ↑ NLR, ↑ inflammatory cytokines (IL-6,
IL-1, TNF α) are common finding in COVID-19 esp. in severe
cases
• Secondary infection often occur in COVID-19 patient
admitted to ICU
• NAAT still be the gold standard in COVID-19 diagnosis but some
studies have shown that RDT have comparable sensitivity in high
viral load specimens
Yuki, K., Fujiogi, M. & Koutsogiannaki, S. COVID-19 pathophysiology: A review. Clin Immunol 215, 108427 (2020). CDC. Labs [Internet]. Centers for Disease Control and Prevention. 2020 24
[cited 2022 Feb 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-guidelines.html
• Confirmatory testing should take no longer than 48 hr after antigen testing using
NP/MT/AN swabs
• Serial tests might be needed if there is an outbreak (one or more cases of COVID-
19) → performed every 3 – 7 days until there are no new cases for 10 days
25
Disease Control and Prevention. 2020 [cited 2022 Feb 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-guidelines.html
CASE
Findings and workups
↑CRP, lymphopenia (ALC <1500), negative RDT SARS-CoV-2 antigen, normal PCT
Hospitalized for at least 48 hours, intubated
CXR: (29/01) normal → (01/02) pneumonia, SOFA score 1

Hospital acquired pneumonia (HAP) d.t bacterial dd/ viral (SARS-CoV-2)

Suggestion
Sputum gram stain, culture and antibiotic sensitivity test, RT PCR SARS-CoV-2
Monitoring
CBC, CRP, PCT, bilirubin T/D/I, ureum, creatinine
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Hyperthyroidism in this Patient

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 Hyperthyroidism
• Syndrome associated with excess thyroid hormone production
• Weight loss, palpitation, heat intolerance, fatigability are symptoms
of hyperthyroid → hypermetabolic state due to excess exposure of
thyroid hormone to peripheral tissues
• Graves disease, adenoma are most common causes of hyperthyroid,
whereas toxic multinodular goiter found more often in older
population
• Thyroid USG could potentially determine the etiology along with
TSH receptor antibodies
• FNAB also necessary especially in patient with high risk of
malignancy
Mathew P, Rawla P. Hyperthyroidism. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Feb 16] 28
Mulita F, Anjum F. Thyroid Adenoma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Feb 17]
 • Excess thyroid hormone might
caused by intrinsic thyroid disease
(primary), ectopic thyroid tissue
(secondary) or dysfunction of
hypothalamus (central)
• Exogenous cause such as infection,
iodine-induced and thyroid
hormone ingestion also can cause
hyperthyroid
• Patient suspected with
hyperthyroid with low FT4 should
be checked for T3 → often elevated
in greater degree in early phase of
graves disease and some case of
solitary, multinodular toxic goiters
(T3 thyrotoxicosis)
29
Carl A. B, David E. B. Tietz Fundamentals of Clinical Chemistry, Seventh Edition. St Louis, Missouri: Elsevier Inc.; 2015.
 Thyroid Auto-Antibodies
• TSH receptor auto-antibodies (TR Ab) that can bind with TSH
receptor is the cause of overreactive thyroid activity
• Other thyroid related auto antibodies such as thyroperoxidase
autoantibodies (TPO Ab) and thyroglobulin (Tg Ab) also can be found
in patient with graves disease
• American Thyroid Association strongly recommended measurement
of TSH- Ab for diagnosis and management of patient with graves
disease
• TR Ab is positive in 85% patient with graves disease and its level
has correlation with chance of remission after 6-12 months of
therapy

Carl A. B, David E. B. Tietz Fundamentals of Clinical Chemistry, Seventh Edition. St Louis, Missouri: Elsevier Inc.; 2015. 30
Kahaly GJ, Diana T. TSH Receptor Antibody Functionality and Nomenclature. Front Endocrinol [Internet]. 2017 Feb 15 [cited 2022 Feb 17];8.
 Thyroid Storm
• Also known as thyrotoxic crisis → syndrome of severe and
accelerating hyperthyroidism with varied clinical symptoms such as
tachycardia, congestive heart failure, fever, coma, etc
• Superimposed precipitating factors (e.g trauma, infections, AMI,
heart failure, etc) might cause thyroid storm with diagnosed or
undiagnosed hyperthyroidism, especially in graves disease
• Diagnosis of thyroid storm needs clinical suspicion based on the
manifestations in patient with hyperthyroidism or suspected
hyperthyroidism

31
Carl A. B, David E. B. Tietz Fundamentals of Clinical Chemistry, Seventh Edition. St Louis, Missouri: Elsevier Inc.; 2015.
Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, et al. 2016 Guidelines for the management of
thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition): The Japan
Thyroid Association and Japan Endocrine Society Taskforce Committee for the establishment 32 of
diagnostic criteria and nationwide surveys for thyroid storm [Opinion]. Endocr J. 2016;63(12):1025–64.
 33
Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, Tsuboi K, et al. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition): The Japan Thyroid Association and Japan Endocrine
Society Taskforce Committee for the establishment of diagnostic criteria and nationwide surveys for thyroid storm [Opinion]. Endocr J. 2016;63(12):1025–64.
CASE
Findings and workups
↑FT4, ↑T3, ↓TSH
Weight loss, intolerance to heat, fatigability, palpitation, diarrhea, lump on neck
(hard with undefined border), tachycardia, fever, intracranial bleeding due to
traffic accident - post operative, BW score: 45, JTA: TS1

Hyperthyroid d.t suspected grave disease dd/ adenocarcinoma on thyroid

storm episode

Suggestion
Thyroid USG, TR Ab, FNAB (if needed), ECG
Monitoring
Vital signs, FT4, T3, TSH
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Case Summary
• It has been discussed 16 y.o patient with post traffic accident
intracranial bleeding presented with lump on neck, history of
clinical signs of hyperthyroid

• Trauma might be one factor that can be precipitating thyroid storm

especially in patient with pre-existing untreated hyperthyroid

• Patient also diagnosed with pneumonia at the second days of

hospitalization that might suggest HAP, but possibility of SARS-CoV-
2 has to be confirmed considering the high number of cases lately
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Case Summary
Suggestion
Thyroid USG, anti TSH receptor-antibody, FNAB (if needed),
ECG, total protein, globulin, bilirubin T/D/I, ALP, gamma GT, UL
sputum gram stain, culture and antibiotic sensitivity test, RT
PCR SARS-CoV-2, peripheral blood smear, reticulocyte, SI, TIBC

Monitoring
Vital signs, FT4, T3, TSH, albumin, CBC, CRP, PCT, SGOT, SGPT,
PT, INR, aPTT, ureum, creatinine

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T h a n k Yo u F o r Yo u r K i n d At t e n t i o n

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