“Glandular intoxication” following emergent tracheotomy during transsphenoidal surgery for acromegaly: Cushing’s 1910 unrecognized case of thyroid storm?

Abstract

Harvey Cushing’s monograph The Pituitary Body and Its Disorders describes Case XXXVIII, H. M. B., a 33 year-old man who presented with acromegaly in 1910. The detailed operative note reports an emergency tracheotomy performed following induction of anesthesia, and immediately prior to a naso-labial approach to a suspected sellar lesion. Cushing’s post-operative notes document a significant increase in temperature prior to the patient’s death. Cushing offered an explanation for the patient’s symptoms immediately pre-mortem, which is largely unsatisfying. Following institutional review board approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records from the Johns Hopkins Hospital, 1896–1912, were reviewed. A review of the original surgical file revealed a more extensive description of the emergent tracheotomy required following induction of anesthesia, and provided additional information regarding the patient’s symptoms in the immediate pre-mortem period. Namely, the urgent tracheotomy transected the thyroid gland, and post-operatively the patient experienced significant tachycardia and hyperthermia, consistent with thyroid storm. The new information regarding the hospital course of H. M. B. offers insight into the previously incompletely described circumstances surrounding his emergent tracheotomy, and subsequent death. Additionally, the case underscores the clinical importance of recognizing and appropriately treating thyroid storm.