AACE2021-A-1003: Metastatic Choriocarcinoma in a Young Woman Presenting as Thyroid Storm

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Thyroid Storm is an endocrine emergency and a life threatening condition which was first discovered in 1926.[1] Its diagnosis is based on a clinical scoring system that includes Burch-Wartofsky point scale and Japanese thyroid association scoring system.[2] The management is based on early diagnosis, immediate initiation of anti-thyroid medications, intensive care monitoring and prevention of multi-organ failure.[3] Here we report a case of thyroid storm in a patient with metastatic choriocarcinoma. A young woman presented with headache vomiting and weakness was in thyroid storm. Later diagnosed as Metastatic choriocarcinoma. A 30 year old female, presented with headache, vomiting and generalized weakness for 3 weeks. She had an episode of seizure like activity at home which cause them to rush to the emergency department. She was febrile on presentation. Thyroid examination revealed a soft, non-tender gland with no enlargement or bruit, and no exophthalmos was identified. Her TSH was extremely low with high free T3 and T4. She also had a high levels of beta-human chorionic gonadotropin hormone. Our patient scored 65 in Burch-Wartofsky point scale. As per Japanese thyroid association scoring system, our patient lies in “definite thyroid storm”.Table: 1Burch-Wartofsky Point Scale (BWPS)Patient parametersPoint scoresTemperature (0C)380C10 pointsCentral Nervous System manifestationSeizures30 pointsGastrointestinal manifestationNausea/Vomiting10 pointsHeart rate105 beats per minute5 pointsCongestive heart failureAbsent0 pointsAtrial FibrillationAbsent0 pointsPrecipitating eventsPresent10 pointsTotal score = 65 points Open table in a new tab She was initiated on propranolol to achieve adequate control of her heart rate and dexamethasone. She was also started on carbimazole. She was then started on cholestyramine to help bind and excrete excess thyroid hormone and Lugol’s iodine solution. Her thyroid function repeated after 2 weeks of treatment shows significant improvement.Table: 2Thyroid profile of the patientInitialAfter treatment (2weeks)Reference RangeTSH<0.010 uIU/ml<0.010 uIU/ml0.4 – 4.2Free T44.74 ng/dl1.61 ng/dl0.89 – 1.76Free T317.90 pg/ml3.40 pg/ml2.1 – 4.4 Open table in a new tab Choriocarcinoma is not only associated with hyperthyroidism but can induce thyroid storm. Beta-hCG has a direct association in promoting thyroid dysfunction. Patient with gestational trophoblastic disease should be closely monitored to prevent thyroid storm.