SUN-570 A Case of Thyroid Storm with Concurrent Active Gastrointestinal Bleed

Objective We describe a patient who presented with thyroid storm and severe gastrointestinal bleed (GIB) and aim to highlight the unique challenges in management. Case A 57-year-old man with a history of psoriasis presented to an outside hospital with palpitations, shortness of breath and diarrhea. Vitals included temperature 98.2F, blood pressure 127/77 mmHg, heart rate 142 bpm with an EKG confirming new onset atrial fibrillation with rapid ventricular rate. Labs included TSH 0.000 mIU/mL (0.35 - 5.50) with a free T4 5.42 ng/dL (0.61 - 1.12). The patient was started on a beta blocker and methimazole (MMI) 10 mg and transferred to our institution for possible cardioversion. Additional labs included Hgb 10.6 g/dL (14-18), platelets 84 K/cm (130-400), ALT 32 U/L (0-45), AST 67 U/L (0-41), ALP 289 U/L (30-115), TBr 5.1 mg/dL (0.2-1.2) and Dbr 4 mg/dL (0-0.2). Echocardiogram confirmed an ejection fraction of 35% and chest radiograph revealed bilateral pleural effusions and pulmonary edema. In preparation for cardioversion, a heparin drip was started resulting in hematemesis, melena and a repeat Hgb of 7.9 g/dL. The patient was intubated, transfused with pRBC’s and started on pantoprazole and octreotide. Endoscopy revealed multiple actively bleeding gastric ulcers treated with clipping. Endocrinology was consulted; the patient was diagnosed with thyroid storm (Burch-Wartofsky ≥ 70 based on known clinical parameters) and treated with an esmolol drip and dexamethasone 1 mg q6h. Due to concern for an active GIB, cholestyramine and SSKI/Lugols were held whereas the dose of MMI was not increased due to worsening transaminitis, doubling of DBr, and downtrending of free T4. After stabilization of the GIB, the patient was extubated with significant clinical improvement. He was discharged on MMI 10 mg and metoprolol tartrate 50 mg BID. Follow-up labs confirmed the diagnosis of Graves’ with TPO 346 IU/mL (0-34), anti-thyroglobulin Ab 31.4 IU/mL (0-0.9) and a TSH-receptor antibody of 15.97 (0-1.75). Thyroid ultrasound revealed heterogenous enlarged gland with no nodules. Conclusion Thyroid storm, a rare but life threatening endocrine emergency is treated by targeting thyroid hormone synthesis, release, conversion to its active form and effects. Active GIB complicates treatment of thyroid storm. First, SSKI/Lugol’s has been shown to be caustic to the GI lining and has been reported to induce a GIB during the treatment of thyroid storm. Second, cholestyramine and steroids have also been associated with an increased risk of GIB. The case was further complicated by worsening transaminitis and hyperbilirubinemia which prevented uptitration of MMI. Despite being limited in treatment options, the patient’s free T4 and clinical symptoms improved on an esmolol drip, dexamethasone and low dose MMI. Our case demonstrates that thyrotoxicosis can be managed despite the treatment limitations posed by an active GIB.