MOFFITT ENDOCRINE REPORT PEARLS 1/11/17: Thyroid Storm and Coarctation of the Aorta!

Thanks to Arielle and Sam for sharing the case of a woman with thyroid storm, and also to Laura for showing an image for a young man with refractory hypertension found to have coarctation of the aorta!

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Top Pearls:

  1. Thyroid storm is a clinical diagnosis based on the following factors: 1) Temperature 2) CNS effects 3) GI/hepatic dysfunction 4) Tachycardia/a-fib 5) Heart failure 6) Precipitant history.
  2. There is typically an underlying cause (Graves most common) and a precipitating event (e.g. surgery, infection, or iodine exposure).
  3. Thyroid storm has high mortality (20-30%)!

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For those who want more info:

See these prior Moffitt pearls about thyroid storm:

https://ucsfmed.wordpress.com/2015/01/27/thyroid-storm/

*Pearl: As Arielle reminded us, a cause of thyroid storm is the withdrawal of a thyroid suppressing medication, such as lithium!

 

Coarctation (narrowing) of the aorta:

  • Location: typically at ductus arteriosus insertion point just distal to left subclavian artery
  • Sequelae: HTN and LV overload (LVH)
  • Epidemiology: M>F (59%)
  • Genetics: Most cases are congenital (present at birth), and there is a suggestion of genetic predisposition, but can be acquired (e.g. Takayasu arteritis)
  • Associations: Turner syndrome, bicuspid aortic valve, VSD, PDA, intracranial aneurysms
  • Natural history: Average survival of 35 years without treatment!
  • Causes of death: Heart failure, aortic rupture/dissection, endocarditis, ICH, MI, arrhythmias
  • Physical exam:
  • *Lower extremity SBP < Upper extremity SBP*
  • *Radial artery to femoral artery pulse delay*
    • Rarely, the coarct is above one or both subclavians, so BPs may differ or all be the same!
    • Continuous heart murmurs due to large collaterals
    • Systolic click from bicuspid valve
  • Notched ribs due to enlarged intercostal vessels (thanks Harry for the Xray!)

rib-notching

  • Echo with complementary CT/MRI is diagnostic (CT reconstruction below):

ct_coarctation_of_the_aorta

  • Treatment: For adults, transcatheter intervention with stenting is the preferred approach, indicated in patients with high gradient or imaging evidence of significant coarctation with collateral flow.

 

Evernote: https://www.evernote.com/shard/s272/sh/58d797da-4dbd-480a-b640-c2cb38b35976/069dac98e5084d08785c9335e04c2027

Have a great day everyone!

Sammy

 

 

Filed under: Cardiovascular Medicine, Endocrinology and Metabolism, Morning Report

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