Thyroid storm has a high mortality rate and is often associated with a precipitating factor such as intercurrent illness or infection. It is rare in pediatric patients. Cardiac disease in hyperthyroidism mostly manifests itself as tachycardia but more serious cardiac findings have also been described. A 5-year-old male with recent strep throat infection presented with dilated cardiomyopathy, hematuria, and symptoms and lab findings consistent with severe hyperthyroidism. He was diagnosed with thyroid storm secondary to concurrent Graves’ disease and poststreptococcal glomerulonephritis (PSGN). After starting the treatment with methimazole and a beta-blocker, his cardiac disease gradually improved and the PSGN resolved over time. There are no specific pediatric criteria for thyroid storm. Adult criteria can be difficult to apply to pediatric cases. Criteria for diagnosis of thyroid storm are less clear for pediatric patients. Dilated cardiomyopathy is a rare cardiac manifestation of hyperthyroidism. PSGN is due to glomerular immune complexes and can complicate group A strep infection. Providers should be aware of cardiac disease as a complication of hyperthyroidism. PSGN should not mechanistically be related to hyperthyroidism but can precipitate the signs of thyroid storm such as hypertension. This association has not been previously reported in the literature.
Hyperthyroidism occurs with an incidence of 1 per 100,000 children, mostly commonly in postpubertal females [
A previously healthy 5-year-old African American male presented to the emergency department with a 9-day history of lethargy, fever, vomiting, weight loss, and diarrhea. The week before presentation, he was diagnosed with streptococcal pharyngitis via rapid antigen testing. He was prescribed a course of oral antibiotics but was noncompliant. On presentation, he was tall and thin (BMI < 3rd percentile, height > 95 percentile) with noticeable goiter and prominent proptosis. He was agitated, restless, tachycardic, and hypertensive (heart rate: 140 beats per minute, blood pressure: 154/99 mmHg). The mother noted that he had always been tall and thin. She had not noted any symptoms of hyperthyroidism such as weight loss, increased appetite, palpitation, or diarrhea prior to this illness. Chest X-ray showed cardiomegaly. Echocardiogram revealed dilated cardiomyopathy with severely dilated left ventricle with severely decreased left ventricular systolic function. Preliminary labs showed significantly elevated pro B-type natriuretic peptide at 19,632 (reference range is <450 pg/mL), suppressed TSH <0.005
In the PICU, he was started on atenolol 25 mg daily and methimazole 5 mg twice daily for hyperthyroidism and given a dose of penicillin G for treatment of his streptococcal pharyngitis. Streptozyme test was positive. He was also noted to have persistent microscopic hematuria and 30 mg/dL of protein on the urine dipstick. Pediatric nephrology was consulted. Renal workup revealed low C3 (60 mg/dL; reference range is 85–288) and normal C4 complement levels (30 mg/dL; reference range is 17–64). He had normal creatinine for his age (0.3 mg/dL). An ASO titer was elevated at 857 (reference range: 0–207 IU/mL). Given the history of recent streptococcal pharyngitis, elevated ASO and streptozyme levels, microscopic hematuria, and low C3, he was presumed to have poststreptococcal glomerulonephritis and was followed up conservatively. Because of the elevated thyroid stimulating immunoglobulin at 464%, he was diagnosed with Graves’ disease. Over the next several days, his heart rate, blood pressure, and mental status improved and his thyroid function tests normalized (see Table
Trend of thyroid function tests during the patient’s hospital course.
Lab value | Day 1 (day of admission) | Day 4 | Day 7 | Day 9 | Day 15 (discharge) |
---|---|---|---|---|---|
TSH ( | <0.006 | <0.006 | <0.006 | <0.006 | <0.006 |
Free T4 (ng/dL) | 7.77 | 3.83 | 2.42 | 1.76 | 1.29 |
TSI (%) | 464% | ||||
Anti-TPO (IU/mL) | 1.3 (indeterminate) | ||||
Antithyroglobulin (IU/mL) | 1.3 (negative) |
Thyroid storm in the setting of Grave’s disease often presents after a precipitating factor. Our patient presented after an episode of acute streptococcal pharyngitis with cardiomyopathy. Thyroid storm is rare in both pediatric patients and adults. The diagnostic criteria are derived from adult thyroid guidelines, where several scoring systems exist. Historically, the most commonly used is the Burch-Wartofsky criteria, which attribute a severity score of 1–5 to individual hallmark features of the disease [
In pediatric patients, the reliability and applicability of these scoring systems are less clear as compared with adults. With prior illness being a common trigger, the etiology of fever may be difficult to attribute to thyroid disease alone. Prepubertal patients in particular have higher resting heart rates at baseline than adults and adolescents. As such, a scoring system for thyroid storm that does not use pediatric age-specific standards for heart rate and temperature is problematic. In addition, CNS dysfunction in a child may be difficult to establish without accounting for developmental staging and age appropriate behavior.
A literature search of thyroid storm in the pediatric population reveals mostly case reports and small case series. Aslan et al. described a case of an 11-year-old patient who presented with a similar condition to our patient with fever, tachycardia, and hypertension in the setting of a viral illness [
Poststreptococcal glomerulonephritis is an uncommon complication of group A streptococcal infections. The incidence is 1.7 to 13.2 per 100,000 and median age is 6–8 years [
The connection between autoimmune diseases is well described, including an association with autoimmune glomerular disease and Graves’ disease. PSGN is mechanistically characterized by immune complexes with subsequent complement activation, which is not autoimmune. It is uncertain whether underlying immunologic derangement may have caused both Graves’ disease and PSGN in our patient or whether the simultaneous appearance of these distinct disease processes was purely coincidental. Perhaps in the future, this association between GD and PSGN can be further elucidated.
In conclusion, we report a case of a 5-year-old African American male with hyperthyroidism and thyroid storm precipitated by a streptococcal infection complicated by poststreptococcal glomerulonephritis presenting with dilated cardiomyopathy and decreased heart function. This case is unique because of the low incidence of thyroid storm in the pediatric population and the concomitant finding of a rare cardiac and renal disease at presentation. To the authors’ knowledge, this association has not been previously reported.
The authors declare that there are no competing interests regarding the publication of this paper.