A51-30 The Perfect Storm: Thyroid Crisis Striking Both Liver and Heart

Abstract Introduction Thyroid storm is a critical, life-threatening consequence of uncontrolled thyrotoxicosis, often leading to multiorgan dysfunction with severe manifestations including acute liver failure (ALF), disseminated intravascular coagulation, arrhythmias, and heart failure (HF), and carries a high risk of mortality. ALF and HF are both extremely rare complications with only a handful of case reports in the literature. We report an unusual case of thyroid storm complicated by both acute hepatic and cardiac failure. Case Presentation A 57-year-old woman with end-stage renal disease on dialysis and heart failure with preserved ejection fraction (EF) presented with abdominal pain and vomiting. She was found to have a non-ST elevation myocardial infarction and underwent cardiac catheterization with stent placement; initial echocardiogram showed normal EF. Her course was complicated by worsening mental status. Labs revealed AST/ALT 1000 U/L, INR 2.2, lactate (13.2 mmol/L), and thyroid dysfunction (TSH 0.010 mIU/L, free T4 5.80 ng/dL, total T4 18.6 µg/dL, free T3 9.9 pg/mL). Endocrinology was consulted, and with a Wartofsky score of 50—likely influenced by HF and encephalopathy—treatment with steroids, methimazole, and iodide was started; beta-blockers were withheld due to absence of tachycardia. TSH receptor antibodies were positive. As transaminitis worsened, methimazole was replaced with cholestyramine, and N-acetylcysteine was started. Repeat echocardiography showed EF of 35-40%, prompting dobutamine for lactic acidosis. Despite initial improvement, the patient developed small bowel obstruction and worsening encephalopathy. Comfort measures were pursued, and she subsequently passed away. Discussion Most thyroid storm cases arise from Graves’ disease, with diagnosis guided by the Burch-Wartofsky scoring system, to assess the extent and severity of organ dysfunction. Despite no prior thyroid history, our patient’s positive TSH receptor antibodies and an elevated Wartofsky score suggested undiagnosed Graves’ disease. Thyroid storm commonly presents with tachycardia, fever, gastrointestinal symptoms, altered mental status, and circulatory failure. Interestingly, our patient did not exhibit fever or tachycardia but experienced a rapid decline in mental status, worsening transaminitis, and persistent hypotension with lactic acidosis, raising concern for cardiogenic shock. A repeat echocardiogram revealed an acute decline in EF that was not present just a few days earlier. Standard therapy uses beta-blockers, antithyroid drugs, iodine, and glucocorticoids, with plasma exchange as an alternative. Unfortunately, antithyroid drugs can worsen ALF and should be used with caution. Cholestyramine is an alternative. Conclusion This case emphasizes that rare complications, including ALF and HF, should be considered in thyroid storm, as early detection and management may improve prognosis. This abstract is funded by: None