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Question: Diagnosis

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A 2yo girl is brought in by ambulance after a seizure lasting 1 minute. She has had 2 days of fever, vomiting, and diarrhea. Her temperature is 39.1, HR 202, BP 129/61. Despite antipyretics, calming down, and volume resuscitation, she remained febrile and tachycardic. On exam, a midline neck mass is palpable, and the mother gives a history of several months of sweating and poor weight gain. A lab test confirms her diagnosis.

Which of the following is appropriate therapy?

pemsou5_wp • August 18, 2020

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  1. Kelly August 22, 2020 - 12:29 pm Reply

    D) Methimazole
    This is a case of thyroid storm reported by Ladd et al in Pediatrics, 2020;145(2):e20191920. The patient had a positive FH of hyperthyroidism. A very low TSH confirmed the diagnosis. Classic symptoms of hyperthyroidism include weight loss, hair loss, palpiations, tremor, tachycardia, and widened pulse pressure. Exam may show thyromegaly, exophthalmos, and hyperreflexia. The patient met criteria for thyroid storm given hyperprexia, tachycardia, GI dysfunction, and seizure. Other presenting symptoms may include CHF, irritability, or lethargy. Most cases are due to Grave’s disease, with autoantibodies stimulating the thyroid. Treatment includes methimazole (blocks thyroid hormone synthesis), propranolol (symptomatic treatment), hydrocortisone (blocks T4 to T3 conversion and protects against adrenal insufficiency), and Lugol’s iodine (prevent new hormone synthesis and release). Propylthiouracil both blocks new hormone synthesis and T4 to T3 conversion but carries a risk of fulminant liver failure, particularly in children.

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