A case of thyroid storm precipitated by H1N1

Rajesh, aged 40 years, one of my employees with confirmed H1N1 flu developed persistent tachycardia, hypotension, restlessness and air hunger. He was managed conservatively in the ICU. Tachycardia was controlled with Ivabradine. But, tachycardia was persisting even after discharge.

We investigated him further. Thyroid profile revealed TSH to be 0.004 suggestive of acute thyroid storm, which was quite possibly precipitated by H1N1 flu.

We carried out a literature search for evidence showing an association between the two. Much to our surprise, there was evidence-based data supporting this association. Cases have been reported of thyroid storm triggered by H1N1 infection.

A case of 31-year-old female with H1N1 precipitating thyroid storm was published by Salim Alawi Baharoon in April 2010 issue of the Annals of Thoracic Medicine. The patient presented with history of high-grade fever, vomiting, productive cough and increasing shortness of breath. She was given empiric antibiotics and oseltamivir along with other treatment. Unexplained tachycardia prompted thyroid function tests, which were suggestive of a diagnosis of thyroid storm (Ann Thorac Med. 2010 Apr;5(2):110-2).

A similar case of H1N1 infection accompanied by thyroid storm was published by Oguz et al in 2010 in Endocrine Abstracts (Endocrine Abstracts. 2010;22:194).

A thyroid storm is a rare life-threatening exacerbation of thyrotoxicosis, and is usually characterized by hyperthermia, tachycardia, severe agitation and altered mental status. It is a medical emergency and carries a mortality of 10%.

Thyroid storm is often precipitated by interruption of thyroid medicine use, acute medical illness, trauma or surgery. Systemic infections such as respiratory infections, endocarditis and urinary tract infections have been known to precipitate a crisis.

The diagnosis of thyroid storm mainly depends on the clinical presentation and results of thyroid function tests. The thyroid stimulating hormone (TSH) level will be abnormally low or even undetectable, and the levels of T3 and T4 will be elevated.

Diagnosis may be delayed due to the nonspecific clinical presentation.

Patients who have survived thyroid storm should receive definite therapy for their underlying hyperthyroidism to avoid any recurrence of this potentially fatal condition.

Although literature does not conclusively establish a cause and effect association between H1N1 flu and thyroid storm, it is still important to know the clinical signs and symptoms of thyroid storm and the condition should be kept in mind as differential diagnosis in patients with unexplained tachyarrhythmia, alterations of consciousness or hypermetabolic status.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

H3N2 Aussies Flu, a near epidemic in Australia, UK and USA: H1N1 in Rajasthan India

H3N2 Aussies Flu, a near epidemic in Australia, UK and USA

H1N1 in Rajasthan India

The flu is rapidly spreading across the US, UK and Australia.

Not only did it start early, but it seemed to occur all over the country more or less simultaneously.

The predominant flu strain is H3N2. Vaccine effectiveness typically ranges from 40 to 60 percent in a good year. Preliminary estimates from last year show the vaccine was 40 percent effective in the U.S., similar to 2014-2015. But concerns have been raised about this year’s vaccine after an editorial published in the New England Journal of Medicine last Thursday said it was only 10 percent effective against H3N2 in Australia.

Additionally, years in which H3N2 is the predominant influenza strain tend to have higher death rates, with approximately 20,000 deaths in the 2012-2013 and 2014-2015 seasons when H3N2 predominated.

Good news is that H3N2 flu is quite susceptible to the available flu medications, like Tamiflu, also known as oseltamivir. Remember, it is most helpful if taken within 48 hours of the start of the flu. It can take up to two weeks for the body to build up defences against the virus.

It is especially important for pregnant women to get the vaccine. There is dual benefit for the pregnant woman to get vaccinated. Not only will she get protection, but she’ll also pass those antibodies along to her infant, which will protect them for the first 6 months of life when the infant is too young to get the vaccine. And the vaccine is safe for pregnant women and the fetus.

For those who contract the flu, it could make symptoms less severe. Next, make sure to wash hands carefully to limit the spread of the virus and try to avoid close contact with sick people.

People who get sick should also keep up with fluids — and seek medical attention if they start to feel worse or develop shortness of breath, worsening congestion or cough.

Public Health Concerns

1.       Trace the first case of H3N2 in India

2.       High risk people to consider vaccinations

3.       Do not allow any person suffering from flu to enter public places

4.       Give compulsory off to people suffering from flu

5.       Learn cough etiquettes and respiratory hygiene

Swine flu kills 95 in north India since January 1: What does this mean?

1.       Swine flu causes fewer deaths than normal seasonal flu.

2.      Hong Kong Study of H1N1 (Between April and December 2009]

a.       Overall attack rate 10.7 percent.

b.      Case-hospitalization rate 0.47 to 0.87 % among people aged 5 to 59 years

c.        Case-ICU rate 7.9 cases per 100,000 infections in children aged 5 to 14 years

d.      Case-ICU rate 75 cases per 100,000 infections in adults aged 50 and 59 years

e.       Case-fatality rate 0.4 cases per 100,000 in children aged 5 to 14 years

f.       Case-fatality rate 26.5 cases per 100,000 in adults aged 50 to 59 years.

3.     Case fatality is 0.4 – 26.5 cases per 100,000. That means 10 deaths would occur if one lac people gets fly. For getting 95 deaths we need almost one crore people getting infected with flu. This again means 10% of the society suffering from flu or two patients per family. Either the figure 95 is wrong or the figure number of positives deaths is wrong.
4.   From 1^st Jan to 7^th Feb (flu season), in 38 days, 95 deaths means 2.5 deaths per day in flu season.  As per Economy Survey of Delhi in total 868 people died of pneumonia in 2006 (year average per day 2.4) and 879 in 2007 (year average per day 2.4).   This statistics is pre H1N1 era and will be true for seasonal flu.

5. 2.4 deaths year long would mean in the flu season the deaths will be much more. This proves the medical fact that swine flu cause fewer deaths than the seasonal flu. Then why panic? 

Padma Shri & Dr. BC Roy National Awardee, Dr. KK Aggarwal, President Heart Care Foundation of India & National Vice President Elect IMA.