CASE REPORT
On December 1, 2020, a 39-year-old man with a previous history of
Graves’ disease for the past three years and lymphoblastic lymphoma
since last year referred to the hospital. He had discontinued
hyperthyroidism treatment since the year before, which was methimazole
10 mg. He had undergone four cycles of chemotherapy, and his lymphoma
disease was in the remission phase. The patient presented with weakness
and fatigue that became severe two weeks before hospitalization. He
reported respiratory symptoms, shortness of breath, diarrhea, and
urinary frequency. He was also restless and had warm and sweaty skin.
Moreover, it is noteworthy that his eye examination results indicated
proptosis. At the time of referral to the hospital, he had a fever (39
˚C) and tachycardia (pulse=140).
The patient had a history of contact with COVID-19 cases during the last
two weeks before admission. Therefore, nasal swabs were collected for
the COVID-19 real-time reverse transcription-polymerase chain reaction
(RT-PCR) test and the result was positive.
According to the results of the high-resolution computed tomography,
there was evidence of patchy areas of ground-glass on the right side.
Moreover, based on the electrocardiogram, the patient had atrial
fibrillation, and his thyroid function indicated suppressed
thyroid-stimulating hormone (TSH) (<0.05 mIU/mL, normal range:
0.35–4.95), elevated free thyroxine (FT4=2 pmol/L, normal range:
0.89-1.7 mg/dl), and normal free triiodothyronine (FT3=2.5 pmol/L,
normal range: 1.7–2.7).The patient was evaluated based on the
diagnostic criteria of Burch et al5. and obtained a
score of 60 which included agitation (10), diarrhea (10), 39 ˚C fever
(20), atrial fibrillation (10), and precipitant history (10).
For this patient, treatment for thyroid, COVID-19, pneumonia, secondary
infection due to COVID-19 was administered which included antibiotics,
vancomycin, imipenem, remdesivir, methimazole, and hydrocortisone.
Symptoms of the patient, including heart palpitation and diarrhea
relieved, and his level of consciousness improved after three days.
Finally, he was discharged in a good general condition after eight days.
The second patient was a 50-year-old man with a 10-year history of
hyperthyroidism and was under treatment, including daily consumption of
methimazole 5 mg. The patient experienced abdominal pain in the left
flank region two weeks before admission to the hospital. Results of the
initial imaging were normal, and the patient was discharged with a
prescription of painkillers and Tavanex antibiotics; nevertheless, the
symptoms and vomiting continued. Moreover, diarrhea and loss of appetite
were added to the symptoms. Gradually, the patient developed a fever and
his level of consciousness decreased as well. Eventually, on October 5,
2020, he was referred to the emergency room of Imam Reza Teaching
Hospital in Mashhad, Iran with delirium, imbalance, and urinary
incontinence. He had a fever of approximately 38.5 ˚C and tachycardia
(pulse=100), while the results of other initial examinations were
normal.
The test results are as follows: thyroid function was assessed, showing
suppressed TSH (<0.01 mIU/mL, normal range: 0.35–4.95),
normal free thyroxine (FT4 4 pmol/L, normal range: 1.7-3.7), and
elevated free triiodothyronine (FT3 3.1 pmol/L, normal range:
0.89–1.76). Moreover, lung computed tomography scan and
echocardiography were normal.
The patient was evaluated based on the diagnostic criteria of Burch et
al.5 and obtained a score of 60 which included
delirium (20), diarrhea, nausea, emesis, and abdominal pain (10), 38.5
˚C fever (15), Tachycardia (5), and precipitant history (10).
A thyroid storm was suspected; hence, proper treatment was
administrated, including hydrocortisone 100 ml, methimazole 10 mg, and
propranolol 20 mg every six h. Given the history of contact with a
positive COVID-19 case, a nasal swab sample was collected and examined
for COVID-19 RT-PCR which was positive. Therefore, the patient was
transferred to the COVID-19 ward for further treatment. In addition to
treatment for thyroid storm, he was treated with remdesivir, interferon,
and injectable antibiotics. His consciousness gradually increased during
the first to sixth days of hospitalization; accordingly, the Glasgow
Coma Scale increased from 9 to 14. He opened his eyes to some extent and
was able to express his needs and make short conversations.
Nevertheless, from the seventh day, he developed respiratory distress
and underwent intubation. He was connected to a mechanical ventilator
and transferred to the COVID intensive care unit; however, the patient
died on the eighth day.