Abstract Thyroid Storm is a rare life-threatening complication of hyperthyroidism often precipitated by infection, trauma, or noncompliance with antithyroid medications. Because initial symptoms can be nonspecific, prompt diagnosis can be delayed when gastrointestinal symptoms predominate. Early recognition and implementation of guideline-based therapy is essential for survival. We present a 41 year old female patient with known history of hyperthyroidism and paroxysmal A fib, non-compliant with antithyroid and rate control medications presented with three days of abdominal pain, nausea, diarrhea and general weakness. On admission she was afebrile with temperature 99.3 F, vitals significant for Respiratory rate 32, Blood Pressure 110/79 mmHg, oxygen saturation 98% on ambient air. EKG showed A fib with RVR 215. Initial Laboratory studies showed leukocytosis 16.4, suppressed TSH 0.01Miu/l, Thyroxine 4.65 and Triiodothyronine 222, elevated BNP 1363, elevated high sensitivity troponin 162, procalcitonin 3.12 and elevated lactate 2.2. Chest XR revealed right lower lobe infiltrate consistent with pneumonia. Echocardiography demonstrated Ejection fraction (EF) 22% severely dilated Left ventricle (LV) and severe LV global hypokinesis consistent with acute decompensated heart failure. Her Burch-Wartofsky score was 60 points and her Japanese thyroid associate criteria was TS1 alternative combination confirming thyroid storm.She was started on methimazole 20 mg, heparin infusion and Cardizem infusion for rate control which was switched to esmolol infusion once in the Intensive Care unit. She was also empirically started on dexamethasone as part of thyroid storm treatment. Despite appropriate measures tachyarrhythmia persisted. Methimazole was replaced with propylthiouracil (PTU), and potassium iodide was started after 6 hours along with Cholestyramine. She also started empiric antibiotics Rocephin and azithromycin towards community acquired pneumonia. Patient eventually decompensated with worsening tachyarrhythmia and hemodynamic instability requiring cardioversion, intubation, mechanical ventilation, vasopressors and discontinuation of esmolol due to concern for cardiogenic shock. Over the next several days hemodynamics stabilized, thyroid function improved, and she was extubated. She was transitioned from PTU to methimazole for maintenance and discharged with beta blocker, diuretics and anticoagulation with endocrinology and cardiology follow up. This case emphasizes several critical aspects of thyroid storm including the importance of high clinical suspicion, prompt treatment of precipitating factors and adherence to guideline based management. Atypical presentations such as gastrointestinal distress can obscure diagnosis. In patients without overt hyperadrenergic signs, symptoms may be mistaken for infection alone; this underscores the importance of early recognition of thyroid storm as timely treatment can be lifesaving. This abstract is funded by: None
Noel et al. (Fri,) studied this question.